Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 1 of 15 PageID #: 26
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 1 of 15 PagelD #: 26
`
`EXHIBIT B
`EXHIBIT B
`
`
`
`
`
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 2 of 15 PageID #: 27
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`
`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, P.C.
`
`
`
`
`
`Plaintiffs,
`
`
` - Against -
`
`
`OXFORD HEALTH INSURANCE CO., INC.,
`OXFORD HEALTH INSURANCE INC., OXFORD
`HEALTH PLANS (NJ), INC.; OXFORD HEALTH
`PLANS (NY), INC.; and OXFORD HEALTH PLANS
`L.L.C.
`
`
`
`
`Plaintiffs, NORMAN MAURICE ROWE, M.D., M.H.A., L.L.C. & EAST COAST
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Index No. 715808/2021
`
`AMENDED COMPLAINT
`
`
`
`
`
`
`
`
`
`Defendants.
`
`PLASTIC SURGERY, P.C., allege:
`
`JURISDICTION AND VENUE
`
`1) This Court has personal jurisdiction over the parties because Defendants,
`
`OXFORD HEALTH INSURANCE CO., INC., OXFORD HEALTH INSURANCE
`
`INC., OXFORD HEALTH PLANS (NJ), INC.; OXFORD HEALTH PLANS (NY),
`
`INC.; and OXFORD HEALTH PLANS L.L.C. are insurance companies licensed and
`
`authorized to do business in the State of New York; OXFORD HEALTH
`
`INSURANCE CO., INC., OXFORD HEALTH INSURANCE INC., OXFORD
`
`HEALTH PLANS (NJ), INC.; OXFORD HEALTH PLANS (NY), INC.; and
`
`OXFORD HEALTH PLANS L.L.C. violated New York Law while doing business in
`
`New York State.
`
`L&B File No.: 2125.COM.34
`
`1 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 3 of 15 PageID #: 28
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`2) OXFORD HEALTH INSURANCE CO., INC., OXFORD HEALTH
`
`INSURANCE INC., OXFORD HEALTH PLANS (NJ), INC.; OXFORD HEALTH
`
`PLANS (NY), INC.; and OXFORD HEALTH PLANS L.L.C. transact business in
`
`QUEENS County.
`
`PARTIES
`
`3) Defendants, OXFORD HEALTH INSURANCE CO., INC., OXFORD
`
`HEALTH INSURANCE INC., OXFORD HEALTH PLANS (NJ), INC.; OXFORD
`
`HEALTH PLANS (NY), INC.; and OXFORD HEALTH PLANS L.L.C. (hereinafter
`
`“OXFORD” or the “Insurer”), are insurance companies licensed and authorized to do
`
`business in the State of New York.
`
`4) Plaintiffs, NORMAN MAURICE ROWE, M.D., M.H.A., L.L.C. & EAST
`
`COAST PLASTIC SURGERY, P.C. (hereinafter “ROWE” or the “Provider”), are
`
`Domestic Professional Services Companies that provide health services in the State
`
`of New York.
`
`FACTUAL ALLEGATIONS
`
`5) ROWE specializes in cosmetic and reconstructive surgery.
`
`6) At all relevant times, OXFORD sold a health insurance product, or acted as
`
`an authorized agent of a health benefits plan, that provided medical benefits (the
`
`"Insurance Product") to “M.A.,” which are the initials of a person to whom OXFORD
`
`L&B File No.: 2125.COM.34
`
`2 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 4 of 15 PageID #: 29
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`assigned Member ID number 1334596902, indicating that OXFORD is a payor of
`
`some or all of the healthcare costs incurred by “M.A.” (hereinafter “M.A.”).
`
`7) In the healthcare industry, the price paid for a particular service by a payor
`
`is determined by whether the healthcare provider is in-network or out-of -network.
`
`8) In the healthcare industry, the price paid by a payor to in-network provider
`
`for a particular service is based upon either an agreement between the healthcare
`
`provider and the payor, or a network agreement in which the payor participates
`
`(herein collectively “in-network rate schedules”); not agreements between the
`
`patient and payor.
`
`9) The in-network rate schedules are neither trade secrets nor are they
`
`confidential.
`
`10) The in-network rate schedules are in the exclusive custody of OXFORD and
`
`can be known through discovery.
`
`11) At all times relevant, ROWE was not an in-network provider under the
`
`Insurance Product sold by OXFORD.
`
`12) On or about November 15, 2019, ROWE contacted OXFORD and spoke to an
`
`individual in OXFORD's surgical pre-approval department or unit. ROWE
`
`identified itself as an out-of-network provider and requested that OXFORD issue a
`
`GAP exception for a breast reduction to be rendered to M.A..
`
`13) In the healthcare industry, a GAP exception, also known as a benefit level
`
`exception, a clinical exception, or clinical GAP exception (hereinafter “GAP
`
`exception”) is an agreement to pay an out-of-network medical provider to render a
`
`L&B File No.: 2125.COM.34
`
`3 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 5 of 15 PageID #: 30
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`specific healthcare service or services during a specific period of time for a specific
`
`price – the in-network rate.
`
`14) In the healthcare industry, GAP exceptions are not routinely issued. GAP
`
`exceptions are not “pre-authorizations” because GAP exceptions change the price
`
`paid by the payor from the out-of-network price to the in-network price; OXFORD
`
`has a routine business procedure for issuing GAP exceptions.
`
`15) Upon issuing the GAP exception the payor is obligated to pay the healthcare
`
`provider the in-network rate if the specific service is rendered within the required
`
`time period.
`
`16) Upon information and belief, OXFORD will issue a GAP exception only when
`
`it does not have a medical provider with the capacity to render a breast reduction to
`
`M.A. with the same capacity as ROWE’S surgeons within in its network or within
`
`the patient’s geographical vicinity. Additionally, the surgical services ROWE
`
`renders are unique because ROWE’S surgeons practice the latest innovative
`
`techniques to reduce scarring and trauma from surgery, short-scar mammaplasty,
`
`nipple-sparing mastectomy, and reconstruction procedures.
`
`17) A GAP exception allows the patient to receive a healthcare service from an
`
`out-of-network provider with reduced out-of-pocket costs the patient is not
`
`otherwise entitled to receive.
`
`18) On December 18, 2019, ROWE submitted to OXFORD clinical information
`
`and certain medical records concerning the surgery proposed for M.A., as requested
`
`by OXFORD.
`
`L&B File No.: 2125.COM.34
`
`4 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 6 of 15 PageID #: 31
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`19) On or about November 22, 2019, OXFORD issued a GAP exception for a
`
`breast reduction to be rendered to M.A.
`
`20) On December 18, 2019, ROWE rendered a breast reduction to M.A.
`
`21) ROWE submitted its billing to OXFORD.
`
`22) OXFORD did not do what it was required to do.
`
`23) OXFORD did not reject ROWE’S performance within 45 days.
`
`24) OXFORD never provided ROWE with any notice of any good faith dispute
`
`regarding the following: eligibility of M.A. 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.
`
`25) OXFORD ultimately issued payment that was late and unreasonable for the
`
`services ROWE provided.
`
`26) The amount paid to ROWE by OXFORD, $6,943.11, is not equal to the in-
`
`network rate, is unreasonable and not consistent with the prevailing and customary
`
`rates the surgery performed by ROWE.
`
`FIRST CAUSE OF ACTION — BREACH OF CONTRACT
`
`27) ROWE repeats and realleges the foregoing and previous paragraphs as if
`
`fully set forth herein.
`
`28) On or about November 22, 2019, ROWE and OXFORD reached an agreement
`
`whereby ROWE rendera breast reduction on M.A.
`
`L&B File No.: 2125.COM.34
`
`5 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 7 of 15 PageID #: 32
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`29) It was agreed OXFORD would pay the in-network rate for the surgery; at
`
`that time the in-network rate was eighty percent (80%) of the billed amount.
`
`30) On December 18, 2019, ROWE rendered a breast reduction to M.A. and
`
`submitted its billing to OXFORD for the services.
`
`31) OXFORD has failed and refused to pay ROWE for those services as agreed
`
`between the parties.
`
`32) OXFORD has failed to pay the balance owed despite demands to do so by
`
`ROWE.
`
`SECOND CAUSE OF ACTION — UNJUST ENRICHMENT
`
`33) ROWE repeats and realleges the foregoing and previous paragraphs as if
`
`fully set forth herein.
`
`34) ROWE conferred a benefit upon OXFORD under circumstances where
`
`OXFORD knew or should have known that ROWE expected to be reasonably
`
`compensated for the benefit conferred according to usual and customary prevailing
`
`rates for the surgery provided to M.A.
`
`35) M.A. sought out ROWE to render a breast reduction because there was no
`
`surgeon in OXFORD’s Insurance Product’s network with the same capacity as
`
`ROWE’s surgeons.
`
`36) ROWE had no obligation to accept OXFORD’s promise of payment, had no
`
`obligation to seek OXFORD’s approval to perform a breast reduction on M.A., no
`
`L&B File No.: 2125.COM.34
`
`6 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 8 of 15 PageID #: 33
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`obligation to perform the surgery within any time period, and had no obligation to
`
`accept OXFORD’s payment for services rendered to M.A.
`
`37) If OXFORD did not issue the GAP exception then M.A. would not have
`
`received a breast reduction from ROWE for the same out-of-pocket costs.
`
`Furthermore, but for the GAP exception, ROWE would not have forbore from
`
`demanding M.A. pay a greater amount up-front prior to the surgery being rendered.
`
`38) The existence of the GAP exception process shows that OXFORD provides a
`
`service in addition to paying for some or all of M.A.’s healthcare services. Upon
`
`information and belief, OXFORD expends more of its resources in terms of dollars
`
`towards relationship cultivation and customer service than clinical determinations
`
`of medical necessity or determining the proper amount of payment.
`
`39) The benefits conferred by ROWE upon OXFORD when ROWE agreed to
`
`render a breast reduction based on OXFORD’s promise of payment included M.A.’s
`
`perception, valid or otherwise, that OXFORD facilitated M.A. receiving a breast
`
`reduction from ROWE at a cheaper out-of-pocket price term when OXFORD did not
`
`have a surgeon in its network with the same capacity as ROWE and M.A. was
`
`otherwise not entitled to receive that service from ROWE at that price term; the
`
`esteem and the expectancy of M.A.’s continued customer patronage is called
`
`goodwill and it has a value to OXFORD.
`
`40) Under the circumstances, it would be unfair to permit OXFORD to retain the
`
`benefits conferred upon it without further compensation to ROWE.
`
`L&B File No.: 2125.COM.34
`
`7 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 9 of 15 PageID #: 34
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`THIRD CAUSE OF ACTION — PROMISSORY ESTOPPEL
`
`41) ROWE repeats and realleges the foregoing and previous paragraphs as if
`
`fully set forth herein.
`
`42) OXFORD clearly and unambiguously promised to pay ROWE at eighty
`
`percent (80%) of the total billed charges for the In-Network level for the medical
`
`services provided to M.A., and should have expected that ROWE would rely upon
`
`that promise.
`
`43) OXFORD should have expected ROWE to rely upon its promise because,
`
`among other reasons, OXFORD knew or should have known that the surgery was
`
`scheduled for December 18, 2019 in accordance with OXFORD’s condition that the
`
`service be rendered within a specific time period, and it made a promise on
`
`November 22, 2019 to pay for a breast reduction rendered to M.A. at the eighty
`
`percent (80%) of the total billed charges for the In-Network rate.
`
`44) OXFORD should have expected ROWE to rely upon its promise because,
`
`among other reasons, OXFORD issued GAP exceptions to ROWE in the past, had
`
`made numerous payments to ROWE for healthcare services rendered by ROWE at a
`
`rate equal to 80 percent of the billed amount after issuing GAP exceptions for the
`
`same surgery.
`
`45) ROWE relied on OXFORD's promise to its detriment, causing substantial
`
`damages equal to the reasonable value of the medical services provided by ROWE.
`
`
`
`L&B File No.: 2125.COM.34
`
`8 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 10 of 15 PageID #: 35
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`FOURTH CAUSE OF ACTION — VIOLATION OF NEW
`YORK’S PROMPT PAY LAW
`
`46) ROWE repeats and realleges the foregoing and previous paragraphs as if
`
`fully set forth herein.
`
`47) ROWE submitted its claim to OXFORD.
`
`48) OXFORD did not issue payment, object to payment, or request further
`
`information from ROWE regarding the claim within forty-five (45) days of receipt of
`
`the claim.
`
`49) ROWE is entitled to payment of $170,268.00, the billed amount, less
`
`$6,943.11 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, P.C. demands judgment in the amount of
`
`$163,324.89 together with interest and costs; or in the alternative judgment in the
`
`amount of $129,271.29 and granting such other and further relief as the Court may
`
`deem just and proper.
`
`LEWIN & BAGLIO, LLP
`Attorneys for the Plaintiffs
`1100 Shames Drive
`Suite 100
`Westbury, New York 11590
`Tel: (516) 307- 1777
`Fax: (516) 307- 1770
`L&B File No.: 2125.COM.34
`
`L&B File No.: 2125.COM.34
`
`9 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 11 of 15 PageID #: 36
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF QUEENS
`NORMAN MAURICE ROWE, M.0., M.H.A., L.L.C. & EAST
`COAST PLASTIC SURGERY, P.C. Plaintiffs,
`•Against-
`OXF0RO HEALTH INSURANCE CO., INC., OXFORD
`HEAL TH INSURANCE INC., OXFORD HEAL TH PLANS
`(NJ), INC.; OXFORD HEAL TH PLANS (NY), INC.; and
`OXFORD HEAL TH PLANS L.L.C.
`Defendants.
`
`Index No. 715808/2021
`AMENDED VERIFICATION
`
`'· 4v-,J::,uE ""• '"'' """'· ··-... ,.,..,
`I am an officer of NORMAN MAURICE ROWE, M.D., M.H.A., L.L.C. & EAST COAST
`PLASTIC SURGERY, P.C., the plaintiffs in the above-entitled action. I have read the
`foregoing amended 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: 11/24/2021
`Sworn to before me this�
`dayof Ll/�.202,{
`
`'
`
`MICHELE SAGURTON
`NOTARY PUBLIC OF NEW JERSEY
`My Commission lixf)lres wi111aoaa
`
`Notary Public
`
`l&B FIie No.: 2125.COM.34
`
`10 of 14
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 12 of 15 PageID #: 37
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF QUEENS
`NORMAN MAURICE ROWE, M.0., M.H.A., L.L.C. & EAST
`COAST PLASTIC SURGERY, P.C. Plaintiffs,
`•Against-
`OXF0RO HEALTH INSURANCE CO., INC., OXFORD
`HEAL TH INSURANCE INC., OXFORD HEAL TH PLANS
`(NJ), INC.; OXFORD HEAL TH PLANS (NY), INC.; and
`OXFORD HEAL TH PLANS L.L.C.
`Defendants.
`
`Index No. 715808/2021
`AMENDED VERIFICATION
`
`'· 4v-,J::,uE ""• '"'' """'· ··-... ,.,..,
`I am an officer of NORMAN MAURICE ROWE, M.D., M.H.A., L.L.C. & EAST COAST
`PLASTIC SURGERY, P.C., the plaintiffs in the above-entitled action. I have read the
`foregoing amended 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: 11/24/2021
`Sworn to before me this�
`dayof Ll/�.202,{
`
`'
`
`MICHELE SAGURTON
`NOTARY PUBLIC OF NEW JERSEY
`My Commission lixf)lres wi111aoaa
`
`Notary Public
`
`l&B FIie No.: 2125.COM.34
`
`11 of 14
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`INDEX NO. 715808/2021
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 13 of 15 PageID #: 38
`Page 13Melpeng. 38, /08/2021
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`—
`
`
`lela
`OAFORD HEALTH PLANS
`
`PO BOX 29130
`
`
`
`HOT SPRINGS,AR 71903-9130
`
`
`
`6. JNSUAANCE PLAN NAME OF PROGRAM NAME
`
`10.18 PATIENT'S CONDITION RELATED Ter
`
`“7b. NEI
`
`|
`
`WEARATEAREte|ADD
`
` ua!ele——AEEAEDRECOEE
`
`“
`HEALTH INSURANCE CLAIM FORM
`APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUICC} cata
`PICA
`lonremem
`
`
`
`
`i. MEDICARE
`MEDICAID
`TRICABE= CHAMPVAGROUP.
`
`
`(For Program initem1)
`
`
`
`"| tectewres) ] (dedinatde} C4 (oaDebey ” [| (Member18) [| Da
`
`[X]ooe|a P6902
`
`
`
`
`2. PATIENT'S NARSE jLaus Nurs, First Name, Miceli fobtlal
`3.
`4, INSVAEG'S MAME (Lia! Macon, Fir) Name, Middia Initial
`
`
`ASHBY, MELODY
`.
`ASHBY, MELODY
`
`
`B. PATIENT'S ADDRESS (Nu,, Breet?
`7INSAEDSs ADDRESS (Nu, Strasi}
`
`
`
`4 BLUEFIELD COURT self[X] spousa| | crite|other[|
`
`
`4 BLUEFIELD COURT
`cITyY
`STATE
`cry
`8. FIESERVED FOR NUCC USE
`HILLSDALE
`Nd
`
`
`HILLSDALE
`
`
`
`ZIP CODE
`TELEPHONE(Include Aras Code)
`2|P CODE
`TELEPHONE (lnmiude Area Coda}
`07642
`(201)312-5612
`(201)312-5612
`
`ee |
`$. OTHERINSUPIECIS NAME (Last Name, Pet Name, Middle toitad
`71. INSURED'S POLICY GROUP OR FECA NUMBER
`
`
`a. OTHERINSURED'S FOLIDY OF GROUP NUMBER | a. RMPLOVMENT? (CarteutPraviousy
`a. INSUBED'S BATE OF BIRTH
`SEX
`
`[-]ves .
`fX]No
`P| SOG
`ml]
`FR]
`
`
`b. RESERVED FOR NUCC USE
`b. AUTO ACCIDENT?
`PLACE (State)
`Sh, aCLAM30 (Degmatadty MUR;
`
`
`esG, OTHER ACCIDENT?
`
`
`o, RESERVED FOR NUCC USE
`
`[| ves
`NO
`
`
`
`di. INGUAANCE PLAN NAME OF SACKIFAM NAME
`
`
`WW. CLAM CODES (Deslgeated by NUE
`4. IS THERE ANOTHER HEALTH BENEFIT PLAN?
`
`
`[“]res
`[Kno
`sryas, cotati tans 8, Oe, wc et
`
`
`AGAD BACK OF FORK BEFORE COMPLETING & HONING THIS FORM.
`
`13, INSURIEO'SOF AUTHORED PERSON'S SINATUAE | aulforas
`
`
`it, PATIENT'S OF ALTHOHIZEO FERNGON'S SIGNATURE J avihorize tha toloase ofasy medical or ather infomamion necessary
`payment of madical banelits lo the dreleraimned pltysician ersupper for
`
`servings daachved baling,
`fo proces fis claim. folew request paynient of government benekin alther lo mysall or 0 the paily whe aecests aeeinament
`hala,
`
`
`04/07/2021
`
`DATE
`
`
`|
`MM)
`oun,|
`0D)
`YY
`
`
`
`
`18. HOBPIYAPATIORDATES RELATED TO CURRENT SERKICES
`
`To
`From 12] 18 [19
`
`
`
`CHARGES
`20, OUTSIDE LAB?
`
`["]ves
`[7 ]no
`
`3 RESUBMISSION
`o6be
`
`i
`
`a
`
`)
`
`1eO ind.
`
`ORIGINAL REF. NO,
`
`.
`&
`21 PAIGE ALITHORIZATION NUMBER
`
`
`A.
`1
`rm
`;
`-
`,
`.
`E.
`
`
`He Leeee Le
`bo Low.
`
`
`
`24.4. G.|0. PROCEDUAES, SEPMICES, OF SUPPLIESDATE(S) OF SERVICE B. E
`
`0
`.
`.
`F.
`&
`|aT
`Lo
`From
`1
`PLACE OF
`{Exploit Unusual Clreumalacnies)
`DIAGNOSIS
`"a lfang|
`ID.
`RENDERING
`
`
`
`
`
`
`MM {Service| EMG|CPTHCPOR uns|Pen|casaBD YY MM obo NY MOOIFIER POINTER §& CHARGES PROVIDEHID.
`
`
`
`"| agisto|121819|24| 19318|Rréo ABC |42567 [00| 1
`
`
`
`
`2) 141819 | 121819|24 | 19318) uTg0|| ‘JaBc 142567 bol 1
`
`
`os
`|
`|
`|
`|
`. 1 YALL Le
`0
`yor
`Vi
`,
`(
`
`—n |
`=
`o5,FEDERALTAXLD.NUMBER 4
`fm BIN
`| 26.PATIENTSACCOUNTNO.
`
`
`
`
`
`28. TOTAL CHAAGE
`28, AMOUNT PAID
`30. Hewel for NUCC Use
`
`% EK]|Seugayg
`
`
`if
`a
`|
`BS
`res
`NO
`s 85134
`8
`52 fii
`
`
`SXGHATUHE QF PHYSICIANDFSUPPLIER
`92, SERVICE FACILITY LOCATION INFORMATION ==~«CU'S) BALLINNGS PROVIDER INFO A PIT
`
`(1 cartity thatthe stateanenta on tha rovers
`DYNAMIC SURGERY CENTER
`BAST COAST PLASTIC SURGERY
`apply ho hig bt alate made a pad irenaaly
`321 BS SEX STREET
`333 BROAD STRERT
`PIERCE, CHARLES A, D|_HACKENSACK,Nd
`REDBANK,NJ07701-2178
`
`12 of 14
`12 of 14
`
`DeesnbearsOeeeETtk
`
`i‘:}
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`:
`
`:
`
`r
`
`4
`
`6
`
`

`

` FILED: QUEENS COUNTY CLERK 12/08/202104:40 PM
`INDEX NO. 715808/2021
`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 14 of 15 PageID #: 39
`NYSCEF pot tor 15"
`VOUULT
`IER _ VOCUITIETIL
`L
`CU UL
`Page 14,06dpaeseet. 322 08/2021
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`-
`
`OXFORD HEALTH PLANS
`PO BOX 29130
`
`m1PADGIED
`
`
`
`PLATSETARESatepreterFALTERSACTH
`
`efot
`
`d. INSUAANCE PLAN NAME OR PAOGRAM NAME
`
`|
`
`Phe WUAL,
`
`
`
`HEALTH INSURANCE CLAIM FORM
`HOT SPRINGS ,AR 71903-9130
`APPROVED BY NATIONAL UNIFORM CLAW COMMITTEE (NUCCT112
`"pRIcA
`
`
`eSTRICARE CH
`OUP
`ECA OTHER 1
`
`For Fragrant Iwhtern1) ~
`
`
`
`‘
`CJdatanter000iB)"OoSULuNG‘Elen Ladi
`
`
`
`
`| 4 INSURED'S NAME{Laat Nama, Firat Name. Mises Inbal
`
`
`
`ASHBY, MELODY
`BPAPATIENT RELATIONSUI TO INSURED
`6. PATIENTS ADDRESS (Nu. Stragt)
`salt[X|[X'] Seouse[|child] ee
`TAINSUREDS ADDRESS INu., Staal
`
`
`
`
`
`
`4 BLUEFIELD COURT
`4 BLUEFIELD COURT
`
` STATE|8. RESERVED FOR NUCC USEcity
`CITY
`STATE
`
`
`
`
`
`Nd
`NJ
`HILLSDALE
`
`HILLSDALE
`
`
`TELEPHONE {Inchide Aréa Cuda)
`
`
`ZIF CODE
`TELEPHONE (lichide Ares Cde)
`
`
`
`@01 )312-5612
`
`07642
`(201 )312-5612
`
`10.08 PATIENT'S CONDITION RELATED TO:
`®. OTHEA INSURED'S NAME (Last Namo, First Namie, Middfs initial
`
`
`] 1. INSURED'S POLICY GROUP OR FECA NUMBEH
`
`NONE
`
`a. OTHER INSUREDPOLICY OF GROLIP NUMBER
`
`a. EMPLOYMENT? {CurraalotPraviows)
`a. INSURED'SDATE OFBINTH
`
`[_]ves
` fK]no
`
`thHER CLAIM ID (Oevignatad by NUCT)
`b. AESEAVED FORNUCC USE
`
`
`
`i. AUTO ACCIDENT?
`PLACE(Stale)
`
`[]ves
` f]no,
`
`
`
`¢, OTHER ACCIDENT?
`c. RESERVED FOR NUCC LISE
`CINSURANCE PLAN NAME OR PROGHAM NAME
`
`
`
`
`
`[] YES
`fx ]No
`
`
`
`
`
`1, CLAIM CODES (Designaigd by NICCH
`d, ES THERE ANOTHER HEALTH BENEFIT PLAN?
`
`
`
`iyes, complate lamP, 98, anid Su,
`[| YES x] NO,
`
`
`
`REAO BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
`13. INSUAED'S OF AUTHORIZED PERSON'S SIGNATHAE F guthrie
`
`
`12, PATIENT'S OF ALTTHORIZED PEAGON'S SIGNATURE | autlonte ite ilaase of any medical or cher inormation necessary
`payment al mada benetie 1 the unsigned phyghian a supplier ine
`sHivices Bescrioad babay,
`
`
`to pronves ftus claim. | alae request payment of govermmadt Gansta either to myseil or te tha party who aecepla assignment
`esto,
`
`™ Signatureon File
`04/07/2021
`
`
`SIGNATURE/ONFEFI LE
`
`
`
`_ DATE
`SIGNED
`~DATE
`OFCURRENTILLNESS:
`Ik
`8.DATES66rI NTHNABLE[9 WORK INCUCOREAENTOCCUPATION
`
`
`
`* cu
`
`
`7.=OFREFERAINGPROWDEROFOTHERSOURCE
`18,HOSPITALPATIONDATESG61ATEDTOCURRENTSERAGES
`
`OUAL|
`FROM
`|
`tr
`|
`|
`
`
`
`
`FROM]2 18 19
`TO
`
`
`
`3), OUTSIDE LAB?
`SCHARGES
`
`—peneanecepecppatanninaamnes LJves__L]n0Jno|
`
`
`
`a
`21. DIAGNOSIS OR NATURE OF ILLNESS OF INJJAY Flsinte Ad. to service ling belay (23E)
`ICD Ind P
`33. BEBUBMISSION
`
`ORIGINAL AEF. NO,
`
`
`M4004
`a N62
`304,
`.
`|
`
`
`
`E.
`FE.
`al
`HI
`23. PRIOR ALTTHORIZATION NUMBER
`
`
`
`LL- —
`a.
`
`
`
`Bi.A. UDATEIS) OF SERVICE
`D. PROCEDURES,SEAVICES, OFGURPLIES
`
`
`
`
`‘i
`as
`RENDERING
`DIAGNOSIS
`From
`(Explain Unusual Clreumstancesy
`
`
`
`
`
`
`
`POINTER
`§ CHARGES
`UNITS
`¥¥
`Wi
`BB
`CPTHCRES
`.
`MODIFIER
`PROVIDER ID, #
`
`
`141819 | 141819 0 19318|RT 1|feT598788127|ABC [42567 DO |
`
`
`
`
`
`
`121849
`121819
`24
`19318 | LT
`[ABC
`/42567 po|
`1
`“wel|L598788127
`OR,
`
`
`|
`|
`.
`.
`[
`or | |
`NPi
`ge) 9°
`
`
`
`
`
`VEEPtedRTDEREFPEAETEATEE
`
`
`
`
`
`
` SSN EIN
`28. TOTAL CHARGE
`
`
`
`
`
`29, AMOUNTPAID
`
`25. FEDERAL TAX LD. NUMBER
`| a7. ACCEPTABSIGNMENT?
`
`NO
`YES
`
`s 865134
`§
`
`
`
`
`1
`32. SERVICE FACHITY LOCATION INFORMATION
`a1. SIGNATURE OF PHYSICIAN OF SUPPLRA
`
`
`
`
`}
`3. AILUNG PROVIDER INFO & PH @
`INCLUDING DEGREES OH CHEDENTIALS
`DYNAMIC SURGRRY CENTER
`{l cartly that iba statamenis on iy raverse
`NORMAN MAURICE ROWE, MD, MHA,
`
`
`
`Opty ta us bil and are meade: @ pate tleareud }
`321 ESSEX STREET
`71 BAST 77TH STREET
`
`
`
`
`|HACKENSACK,NJ_07601-2066||
`ROWE, NORMAN MD
`NEW YORK,NY-10075- 1827
`
`
`20, Fiswel for NUCC Lise
`|
`
`.
`
`13 of 14
`13 of 14
`
`

`

`INDEX NO. 715808/2021
`FILED: QUEENS COUNTY CLERK 12/08/2021 04:40 PM
`Case 1:22-cv-00117-EK-CLP Document 1-2 Filed 01/07/22 Page 15 of 15 PageID #: 40
`NYSCEF DOC. NO. 15
`RECEIVED NYSCEF: 12/08/2021
`
`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, P.C.
`
`
`
`
`
`
`Plaintiffs,
`
`
` - Against -
`
`
`OXFORD HEALTH INSURANCE CO., INC., OXFORD
`HEALTH INSURANCE INC., OXFORD HEALTH
`PLANS (NJ), INC.; OXFORD HEALTH PLANS (NY),
`INC.; and OXFORD HEALTH PLANS L.L.C.
`
`
`
`
`
`Defendants.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Index No. 715808/2021
`
`
`
`
`
`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 Amended Complaint are not frivolous
`
`
`
`___________________________________________
`By: Michael Baglio, Esq.
`
`
`Notice Pursuant to CPLR 2103(5) declining service by electronic transmittal
`
`
`AMENDED COMPLAINT
`
`
`
`LEWIN & BAGLIO, LLP
`
`Attorneys for the Plaintiffs
`1100 Shames Drive
`Suite 100
`Westbury, New York 11590
`Tel: (516) 307- 1777
`Fax: (516) 307- 1770
`L&B File No.: 2125.COM.34
`
`To:
`
`Attorney for defendants
`Service of a copy of the within AMENDED COMPLAINT is hereby admitted.
`
`Dated:
`
`
`
`
`
`
`
`
`______________________
`Attorney for Defendants
`
`
`
`
`
`
`
`
`
`
`
`
`
`L&B File No.: 2125.COM.34
`
`14 of 14
`
`DocuSign Envelope ID: 3C0CF9AA-9624-4A09-9B8D-BF0A318665BD
`
`