Case 2:19-cv-04817-DRH-ARL Document 5 Filed 08/30/19 Page 1 of 407 PageID #: 26
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`UNITED STATES DISTRICT COURT
`UNITED STATES DISTRICT COURT
`EASTERN DISTRICT OF NEW YORK
`EASTERN DISTRICT OF NEW YORK
`- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - x
`x
`
`::
`
`Docket No. 19-cv-04817 (DRH)(ARL)
`Docket No. 19-cv-04817 (DRH)(ARL)
`
`NEUROLOGICAL SURGERY, P.C.,
`NEUROLOGICAL SURGERY, P.C.,
`
`Plaintiff,
`Plaintiff,
`
`-against-
`-against-
`
`AETNA HEALTH INC. and AETNA HEALTH
`AETNA HEALTH INC. and AETNA HEALTH
`INSURANCE COMPANY OF NEW YORK,
`INSURANCE COMPANY OF NEW YORK,
`
`Defendants.
`Defendants.
`
`
`COMPLAINT
`:
`: COMPLAINT
`:
`:
`:
`:
`Case Removed from the New York
`:
`Case Removed from the New York
`Supreme Court, Nassau County
`:
`: Supreme Court, Nassau County
`:
`:
`JURY TRIAL DEMANDED
`: JURY TRIAL DEMANDED
`:
`:
`- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - x
`x
`
`
`Plaintiff, Neurological Surgery, P.C (“NSPC”), by its attorneys, Garfunkel Wild, P.C.,
`Plaintiff, Neurological Surgery, P.0 ("NSPC"), by its attorneys, Garfunkel Wild, P.C.,
`
`alleges for its Complaint against the Defendants, Aetna Health Inc. and Aetna Health Insurance
`alleges for its Complaint against the Defendants, Aetna Health Inc. and Aetna Health Insurance
`
`Company of New York (collectively, “Aetna”), that:
`Company of New York (collectively, "Aetna"), that:
`
`INTRODUCTION
`INTRODUCTION
`
`1.
`1.
`
`Plaintiff is NSPC, a Long Island-based medical practice, which brings this lawsuit
`Plaintiff is NSPC, a Long Island-based medical practice, which brings this lawsuit
`
`against Aetna because Aetna has failed to properly and timely honor its obligation to pay NSPC
`against Aetna because Aetna has failed to properly and timely honor its obligation to pay NSPC
`
`for medically necessary services that NSPC provided to the members and/or subscribers of
`for medically necessary services that NSPC provided to the members and/or subscribers of
`
`Aetna’s health plans and their beneficiaries (collective, “Aetna Members”).
`Aetna's health plans and their beneficiaries (collective, "Aetna Members").
`
`2.
`2.
`
`As we explain in detail below, NSPC is the largest private neurosurgery practice
`As we explain in detail below, NSPC is the largest private neurosurgery practice
`
`on Long Island and in the tri-state area. Its award-winning specialists are among the best
`on Long Island and in the tri-state area. Its award-winning specialists are among the best
`
`neurosurgeons in New York City and on Long Island and serve as Chiefs of Neurosurgery in
`neurosurgeons in New York City and on Long Island and serve as Chiefs of Neurosurgery in
`
`some of the most prestigious hospitals on Long Island.
`some of the most prestigious hospitals on Long Island.
`
`3.
`3.
`
`NSPC maintains offices in Great Neck, Rockville Centre, Lake Success,
`NSPC maintains offices in Great Neck, Rockville Centre, Lake Success,
`
`Bethpage, Commack, West Islip, Port Jefferson Station, Patchogue, Queens, and Manhattan. It
`Bethpage, Commack, West Islip, Port Jefferson Station, Patchogue, Queens, and Manhattan. It
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`has developed Centers of Excellence in a wide variety of neurosurgery and related subspecialties,
`has developed Centers of Excellence in a wide variety of neurosurgery and related subspecialties,
`
`including a Brain Tumor Center, Spine Center, Trigeminal Neuralgia and Face Pain Center,
`including a Brain Tumor Center, Spine Center, Trigeminal Neuralgia and Face Pain Center,
`
`Cerebrovascular/Neuroendovascular Center, Pediatric Neurosurgery Center, General
`Cerebrovascular/Neuroendovascular Center, Pediatric Neurosurgery Center, General
`
`Neurosurgery Center, Movement Disorder Center, Epilepsy Center, Concussion Center,
`Neurosurgery Center, Movement Disorder Center, Epilepsy Center, Concussion Center,
`
`Stereotactic Radiosurgery Center, Chiari Malformation Center, and Pain Center.
`Stereotactic Radiosurgery Center, Chiari Malformation Center, and Pain Center.
`
`4.
`4.
`
`Upon information and belief, Defendants Aetna Health Inc. and Aetna Health
`Upon information and belief, Defendants Aetna Health Inc. and Aetna Health
`
`Insurance Company of New York are both subsidiaries of Aetna, Inc., a health insurance
`Insurance Company of New York are both subsidiaries of Aetna, Inc., a health insurance
`
`company that entered into an agreement in December 2017 to be acquired by CVS Health
`company that entered into an agreement in December 2017 to be acquired by CVS Health
`
`Corporation at the record price of $69 billion.
`Corporation at the record price of $69 billion.
`
`5.
`5.
`
`Aetna enters into agreements with health care providers whereby the providers
`Aetna enters into agreements with health care providers whereby the providers
`
`join its “provider networks.” The physicians that join the provider network agree to provide
`join its "provider networks." The physicians that join the provider network agree to provide
`
`health care services to members of the health plan at contractually agreed upon reimbursement
`health care services to members of the health plan at contractually agreed upon reimbursement
`
`rates, which are typically discounted rates, compared to the providers’ usual and customary rates.
`rates, which are typically discounted rates, compared to the providers' usual and customary rates.
`
`Such providers are known as “in-network” providers.
`Such providers are known as "in-network" providers.
`
`6.
`6.
`
`Other providers, like NSPC, do not enter into contracts with Aetna, and bill the
`Other providers, like NSPC, do not enter into contracts with Aetna, and bill the
`
`usual, customary, and reasonable charges for the services rendered. Such providers are known as
`usual, customary, and reasonable charges for the services rendered. Such providers are known as
`
`“out-of-network” or “non-participating” providers.
`"out-of-network" or "non-participating" providers.
`
`7.
`7.
`
`Upon information and belief, a substantial number of Aetna’s agreements with its
`Upon information and belief, a substantial number of Aetna's agreements with its
`
`subscribers or members and their beneficiaries give these Aetna Members the right to seek
`subscribers or members and their beneficiaries give these Aetna Members the right to seek
`
`medically necessary treatment from health care providers who are not participating providers in
`medically necessary treatment from health care providers who are not participating providers in
`
`Aetna’s health care networks.
`Aetna's health care networks.
`
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`8.
`8.
`
`Under these agreements, when an out-of-network provider renders medically
`Under these agreements, when an out-of-network provider renders medically
`
`necessary treatment to an Aetna Member, Aetna is obligated to reimburse the Aetna Member or
`necessary treatment to an Aetna Member, Aetna is obligated to reimburse the Aetna Member or
`
`out-of-network provider at the usual, customary, and reasonable charges for the services
`out-of-network provider at the usual, customary, and reasonable charges for the services
`
`rendered, less any co-payment, co-insurance, member out-of-pocket, or deductible amounts.
`rendered, less any co-payment, co-insurance, member out-of-pocket, or deductible amounts.
`
`(This amount is the “UCR Rate.”)
`(This amount is the "UCR Rate.")
`
`9.
`9.
`
`By its own choice, NSPC is not a participating provider in Aetna’s networks.
`By its own choice, NSPC is not a participating provider in Aetna's networks.
`
`Notwithstanding NSPC’s status as a non-participating provider, NSPC routinely receives
`Notwithstanding NSPC's status as a non-participating provider, NSPC routinely receives
`
`authorizations and assignments from its patients who are Aetna Members to receive payment
`authorizations and assignments from its patients who are Aetna Members to receive payment
`
`directly from Aetna.
`directly from Aetna.
`
`10.
`10.
`
`This litigation arises primarily out of Aetna’s wrongful failure and refusal to
`This litigation arises primarily out of Aetna's wrongful failure and refusal to
`
`reimburse NSPC – in many cases, at all, and in other cases, at anything more than a dramatically
`reimburse NSPC — in many cases, at all, and in other cases, at anything more than a dramatically
`
`reduced rate – for medically necessary services that NSPC’s surgeons provided to Aetna
`reduced rate — for medically necessary services that NSPC's surgeons provided to Aetna
`
`Members.
`Members.
`
`11.
`11.
`
`As set forth below, Aetna’s persistent refusal to pay for NSPC’s services has
`As set forth below, Aetna's persistent refusal to pay for NSPC's services has
`
`breached myriad legal obligations and violated federal and state law. Accordingly, NSPC is
`breached myriad legal obligations and violated federal and state law. Accordingly, NSPC is
`
`entitled to the relief demanded in this Complaint.
`entitled to the relief demanded in this Complaint.
`
`PARTIES
`PARTIES
`
`12.
`12.
`
`Plaintiff NSPC is a New York professional corporation with its principal place of
`Plaintiff NSPC is a New York professional corporation with its principal place of
`
`business located at 100 Merrick Road, Suite 128W, Rockville Centre, New York.
`business located at 100 Merrick Road, Suite 128W, Rockville Centre, New York.
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`13.
`13.
`
`Upon information and belief Defendant Aetna Health Inc. is a New York for-
`Upon information and belief Defendant Aetna Health Inc. is a New York for-
`
`profit health maintenance organization with a principal place of business located at 151
`profit health maintenance organization with a principal place of business located at 151
`
`Farmington Avenue, Hartford, Connecticut.
`Farmington Avenue, Hartford, Connecticut.
`
`14.
`14.
`
`Upon information and belief Defendant Aetna Health Insurance Company of New
`Upon information and belief Defendant Aetna Health Insurance Company of New
`
`York is a New York for-profit health insurance company with a principal place of business
`York is a New York for-profit health insurance company with a principal place of business
`
`located at 333 Earle Ovington Boulevard, Suite 104, Uniondale, New York.
`located at 333 Earle Ovington Boulevard, Suite 104, Uniondale, New York.
`
`FACTUAL ALLEGATIONS COMMON TO ALL CLAIMS
`FACTUAL ALLEGATIONS COMMON TO ALL CLAIMS
`
`Aetna Has Failed to Pay NSPC’s Out-of-Network
`Aetna Has Failed to Pay NSPC's Out-of-Network
`Claims at All, or Has Failed to Pay at the Correct Rate
`Claims at All, or Has Failed to Pay at the Correct Rate
`
`15. Many of the patients who seek out and are treated by NSPC have complex, and
`15. Many of the patients who seek out and are treated by NSPC have complex, and
`
`often emergent, neurological conditions requiring neurosurgical procedures and treatment.
`often emergent, neurological conditions requiring neurosurgical procedures and treatment.
`
`16.
`NSPC’s physicians perform these procedures at hospitals and other healthcare
`16. NSPC's physicians perform these procedures at hospitals and other healthcare
`
`facilities located throughout the New York metropolitan area.
`facilities located throughout the New York metropolitan area.
`
`17.
`A significant number of NSPC’s patients have health insurance coverage from
`17. A significant number of NSPC's patients have health insurance coverage from
`
`Aetna, or are members, subscribers, or beneficiaries of group health plans for which Aetna is the
`Aetna, or are members, subscribers, or beneficiaries of group health plans for which Aetna is the
`
`plan sponsor or administrator.
`plan sponsor or administrator.
`
`18.
`18.
`
`As set forth in detail below, in addition to offering fully-insured health plans,
`As set forth in detail below, in addition to offering fully-insured health plans,
`
`Aetna acts as the plan sponsor or administrator of self-insured group health plans by making
`Aetna acts as the plan sponsor or administrator of self-insured group health plans by making
`
`determinations regarding plan interpretation, coverage, the awarding or denial of benefits, the
`determinations regarding plan interpretation, coverage, the awarding or denial of benefits, the
`
`processing and determination of appeals, and the payment of benefits.
`processing and determination of appeals, and the payment of benefits.
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`19.
`A substantial number of Aetna’s agreements with its subscribers or members give
`19. A substantial number of Aetna's agreements with its subscribers or members give
`
`these Aetna Members the right to seek medically necessary treatment from health care providers
`these Aetna Members the right to seek medically necessary treatment from health care providers
`
`who are not participating providers in Aetna’s health care networks.
`who are not participating providers in Aetna's health care networks.
`
`20.
`20.
`
`Under these agreements, when an out-of-network provider renders medically
`Under these agreements, when an out-of-network provider renders medically
`
`necessary treatment to an Aetna Member, Aetna is often obligated to reimburse the Aetna
`necessary treatment to an Aetna Member, Aetna is often obligated to reimburse the Aetna
`
`Member or out-of-network provider at the UCR Rate, or a percentage thereof, based upon the
`Member or out-of-network provider at the UCR Rate, or a percentage thereof, based upon the
`
`Member’s plan.
`Member's plan.
`
`21.
`21.
`
`Alternately, under Section 2719A(b) of the Public Health Service Act, 42 U.S.C.
`Alternately, under Section 2719A(b) of the Public Health Service Act, 42 U.S.C.
`
`§ 300gg-19a(b), and 29 C.F.R. § 2590.715–2719A(b), Aetna, as the sponsor or administrator of
`§ 300gg-19a(b), and 29 C.F.R. § 2590.715-2719A(b), Aetna, as the sponsor or administrator of
`
`any self-insured group health plan, must provide coverage for out-of-network emergency health
`any self-insured group health plan, must provide coverage for out-of-network emergency health
`
`care services, and must do so at the greatest of (a) the median in-network rate that the plan pays
`care services, and must do so at the greatest of (a) the median in-network rate that the plan pays
`
`for the same services; (b) the rate that the plan pays for out-of-network services, which is
`for the same services; (b) the rate that the plan pays for out-of-network services, which is
`
`typically based upon the UCR Rate; and (c) the rate offered by Medicare. In addition, Aetna
`typically based upon the UCR Rate; and (c) the rate offered by Medicare. In addition, Aetna
`
`may not impose any greater administrative requirement or limitation on coverage for out-of-
`may not impose any greater administrative requirement or limitation on coverage for out-of-
`
`network emergency services than it does for in-network emergency services, nor can it impose
`network emergency services than it does for in-network emergency services, nor can it impose
`
`greater co-payments, co-insurance, member out-of-pocket, or deductible amounts for its
`greater co-payments, co-insurance, member out-of-pocket, or deductible amounts for its
`
`members for out-of-network emergency services than it does for in-network emergency services.
`members for out-of-network emergency services than it does for in-network emergency services.
`
`22.
`22.
`
`Similarly, Sections 3216(i)(9), 3221(k)(4), and 4303(a)(2) of the New York
`Similarly, Sections 3216(i)(9), 3221(k)(4), and 4303(a)(2) of the New York
`
`Insurance Law require Aetna to provide members of its fully-insured plans with coverage for
`Insurance Law require Aetna to provide members of its fully-insured plans with coverage for
`
`medically necessary emergency medical services.
` Additionally, Sections 3217-a(a)(8),
`medically necessary emergency medical services. Additionally, Sections 3217-a(a)(8),
`
`3221(k)(4), 4303(a)(2), and 4900(c) of the New York Insurance Law, and Section 4408(1)(h) of
`3221(k)(4), 4303(a)(2), and 4900(c) of the New York Insurance Law, and Section 4408(1)(h) of
`
`the New York Public Health Law, require that Aetna, when offering a managed care product,
`the New York Public Health Law, require that Aetna, when offering a managed care product,
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`hold their members harmless for any non-participating provider charges for emergency services
`hold their members harmless for any non-participating provider charges for emergency services
`
`that exceed the in-network copayment, coinsurance, or deductible.
`that exceed the in-network copayment, coinsurance, or deductible.
`
`23.
`23.
`
`By its own choice, NSPC is not a participating provider in Aetna’s networks.
`By its own choice, NSPC is not a participating provider in Aetna's networks.
`
`Notwithstanding its status as an Aetna non-participating provider, NSPC routinely receives
`Notwithstanding its status as an Aetna non-participating provider, NSPC routinely receives
`
`authorization and assignments from its patients who are Aetna Members to receive payment
`authorization and assignments from its patients who are Aetna Members to receive payment
`
`directly from Aetna.
`directly from Aetna.
`
`24. When patients elect to assign their benefits under their Aetna insurance plans,
`24. When patients elect to assign their benefits under their Aetna insurance plans,
`
`they execute an assignment of benefits form.
`they execute an assignment of benefits form.
`
`25.
`25.
`
`Regardless of whether of not the applicable health plans at issue contain anti-
`Regardless of whether of not the applicable health plans at issue contain anti-
`
`assignment clauses, Aetna has accepted and acknowledged the assignments of benefits at issue in
`assignment clauses, Aetna has accepted and acknowledged the assignments of benefits at issue in
`
`this lawsuit because, as detailed below, Aetna communicated with, paid, and otherwise dealt
`this lawsuit because, as detailed below, Aetna communicated with, paid, and otherwise dealt
`
`directly with NSPC in connection with the health claims at issue. Such dealings and course of
`directly with NSPC in connection with the health claims at issue. Such dealings and course of
`
`conduct overrode and affected a waiver of any anti-assignment clause.
`conduct overrode and affected a waiver of any anti-assignment clause.
`
`26.
`26.
`
`Additionally, to the extent that Aetna’s plans contain anti-assignment language,
`Additionally, to the extent that Aetna's plans contain anti-assignment language,
`
`such anti-assignment language is ineffective to bar an assignment as a matter of law.
`such anti-assignment language is ineffective to bar an assignment as a matter of law.
`
`27.
`27.
`
`By NSPC’s assignments of benefits from Aetna Members, contractual
`By NSPC's assignments of benefits from Aetna Members, contractual
`
`relationships were created by which Aetna is obligated to reimburse NSPC directly for the
`relationships were created by which Aetna is obligated to reimburse NSPC directly for the
`
`services provided to the Aetna Members.
`services provided to the Aetna Members.
`
`28.
`28.
`
`On the dates of service set forth below, the Aetna Members listed below presented
`On the dates of service set forth below, the Aetna Members listed below presented
`
`to NSPC with health conditions requiring NSPC to provide them with medically necessary health
`to NSPC with health conditions requiring NSPC to provide them with medically necessary health
`
`care services.
`care services.
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`29.
`29.
`
`As explained below, these health care services were covered services under the
`As explained below, these health care services were covered services under the
`
`applicable health plan documents.
`applicable health plan documents.
`
`30.
`30.
`
`Aetna was aware at or around the times that Aetna Members received the health
`Aetna was aware at or around the times that Aetna Members received the health
`
`care services at issue that NSPC provided these persons with covered health care services.
`care services at issue that NSPC provided these persons with covered health care services.
`
`31.
`31.
`
`Aetna, as detailed below, engaged in communications or discussions with NSPC
`Aetna, as detailed below, engaged in communications or discussions with NSPC
`
`acknowledging – or at the very least manifesting its awareness – that NSPC was providing the
`acknowledging — or at the very least manifesting its awareness — that NSPC was providing the
`
`Aetna Members with covered health care services.
`Aetna Members with covered health care services.
`
`32.
`32.
`
`In all situations, NSPC was justified in providing medical services to the Aetna
`In all situations, NSPC was justified in providing medical services to the Aetna
`
`Members, and in expecting payment, because it was mutually understood that Aetna would
`Members, and in expecting payment, because it was mutually understood that Aetna would
`
`reimburse NSPC for medically necessary services covered under the applicable health plan
`reimburse NSPC for medically necessary services covered under the applicable health plan
`
`documents.
`documents.
`
`33.
`33.
`
`Given these facts and circumstances, NSPC reasonably expected that Aetna
`Given these facts and circumstances, NSPC reasonably expected that Aetna
`
`would pay for these covered services at the rates and levels required under applicable health plan
`would pay for these covered services at the rates and levels required under applicable health plan
`
`documents, as well as federal and state law.
`documents, as well as federal and state law.
`
`34.
`34.
`
`By reason of the foregoing, express contracts or contracts implied-in-fact arose
`By reason of the foregoing, express contracts or contracts implied-in-fact arose
`
`between Aetna and NSPC (the “Contracts”), whereby NSPC agreed to provide covered health
`between Aetna and NSPC (the "Contracts"), whereby NSPC agreed to provide covered health
`
`care services to Aetna Members in exchange for Aetna paying NSPC for those covered health
`care services to Aetna Members in exchange for Aetna paying NSPC for those covered health
`
`care services at the rates and levels set forth under applicable health plan documents, as well as
`care services at the rates and levels set forth under applicable health plan documents, as well as
`
`federal and state law.
`federal and state law.
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`35.
`35.
`
`Based upon the claims forms submitted and information provided to Aetna, its
`Based upon the claims forms submitted and information provided to Aetna, its
`
`obligation to pay the claims for services listed below was, and should have been, reasonably
`obligation to pay the claims for services listed below was, and should have been, reasonably
`
`clear to Aetna in accordance with section 3224-a of the New York Insurance Law.
`clear to Aetna in accordance with section 3224-a of the New York Insurance Law.
`
`36.
`36.
`
`Based on Aetna’s representations regarding payment to NSPC, and the provisions
`Based on Aetna's representations regarding payment to NSPC, and the provisions
`
`of the federal Public Health Service Act and the New York Insurance and Public Health Laws,
`of the federal Public Health Service Act and the New York Insurance and Public Health Laws,
`
`NSPC provided the health care services detailed below expecting to be promptly and properly
`NSPC provided the health care services detailed below expecting to be promptly and properly
`
`paid for the services that were performed, medically necessary, and billed appropriately.
`paid for the services that were performed, medically necessary, and billed appropriately.
`
`37.
`37.
`
`Unfortunately, this has not been the case.
`Unfortunately, this has not been the case.
`
`38.
`38.
`
`In many of the claims for health care services listed below, Aetna has completely
`In many of the claims for health care services listed below, Aetna has completely
`
`failed – in some cases for several years – to pay anything for the medically necessary and
`failed — in some cases for several years — to pay anything for the medically necessary and
`
`covered treatment provided by NSPC.
`covered treatment provided by NSPC.
`
`39.
`39.
`
`And, in those cases in which Aetna paid something for the medically necessary
`And, in those cases in which Aetna paid something for the medically necessary
`
`and covered treatment provided by NSPC to Aetna Members, the amount paid was was far below
`and covered treatment provided by NSPC to Aetna Members, the amount paid was was far below
`
`the required rate and payment was long delayed for no reasonable justification.
`the required rate and payment was long delayed for no reasonable justification.
`
`40.
`40.
`
`For months, and in some cases, years, NSPC has attempted to enter into a
`For months, and in some cases, years, NSPC has attempted to enter into a
`
`meaningful dialog with Aetna so as to obtain prompt and proper payment for the outstanding
`meaningful dialog with Aetna so as to obtain prompt and proper payment for the outstanding
`
`claims detailed below.
`claims detailed below.
`
`41.
`41.
`
`Unfortunately, NSPC’s efforts have largely fallen on deaf ears. All that the effort
`Unfortunately, NSPC's efforts have largely fallen on deaf ears. All that the effort
`
`has produced are vague letters and promises of proper payment at some uncertain point in the
`has produced are vague letters and promises of proper payment at some uncertain point in the
`
`future, endless requests and re-requests for documents supporting the claims, and vague
`future, endless requests and re-requests for documents supporting the claims, and vague
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`allegations or intimations regarding supposedly valid defenses to the outstanding claims, which
`allegations or intimations regarding supposedly valid defenses to the outstanding claims, which
`
`never seem to materialize.
`never seem to materialize.
`
`42.
`42.
`
`Accordingly, having exhausted all reasonable administrative remedies and
`Accordingly, having exhausted all reasonable administrative remedies and
`
`appeals – to the point where further administrative actions and appeals would be futile –NSPC
`appeals — to the point where further administrative actions and appeals would be futile —NSPC
`
`has been forced to commence this lawsuit.
`has been forced to commence this lawsuit.
`
`43.
`43.
`
`Detailed below are the health care claims at issue in this lawsuit. Because of
`Detailed below are the health care claims at issue in this lawsuit. Because of
`
`privacy concerns, a code is used for each patient. The code will be supplied to Defendants and
`privacy concerns, a code is used for each patient. The code will be supplied to Defendants and
`
`the Court, in camera.
`the Court, in camera.
`
`JA – 12/17/2015
`JA — 12/17/2015
`
`44.
`44.
`
`On December 17, 2015, NSPC provided JA with medically necessary elective
`On December 17, 2015, NSPC provided JA with medically necessary elective
`
`health services in connection with JA’s diagnosis of localization-related symptomatic epilepsy
`health services in connection with JA's diagnosis of localization-related symptomatic epilepsy
`
`and epileptic syndromes with complex partial seizures, intractable, without status epilepticus.
`and epileptic syndromes with complex partial seizures, intractable, without status epilepticus.
`
`45.
`45.
`
`The services included procedures on the skull, meninges, and brain, among other
`The services included procedures on the skull, meninges, and brain, among other
`
`procedures.
`procedures.
`
`46.
`46.
`
`At the time the services were provided, JA was a member, subscriber, or
`At the time the services were provided, JA was a member, subscriber, or
`
`beneficiary of a health plan administered by Aetna.
`beneficiary of a health plan administered by Aetna.
`
`47.
`47.
`
`The health services provided by NSPC to JA on December 17, 2015 were
`The health services provided by NSPC to JA on December 17, 2015 were
`
`medically necessary, covered health services under the relevant Aetna health plan documents.
`medically necessary, covered health services under the relevant Aetna health plan documents.
`
`4197621v.8
`4197621v.8
`
`9
`9
`
`

`

`Case 2:19-cv-04817-DRH-ARL Document 5 Filed 08/30/19 Page 10 of 407 PageID #: 35
`
`48.
`48.
`
`At or around the time the medically necessary health services were provided, JA
`At or around the time the medically necessary health services were provided, JA
`
`presented cards or other documentation to NSPC indicating that Aetna was contractually
`presented cards or other documentation to NSPC indicating that Aetna was contractually
`
`required to pay for the health services provide when JA incurred liability to pay said bills.
`required to pay for the health services provide when JA incurred liability to pay said bills.
`
`49.
`49.
`
`On July 22, 2011, JA also executed documents assigning to NSPC all rights to
`On July 22, 2011, JA also executed documents assigning to NSPC all rights to
`
`receive reimbursement from Aetna for the health care services provided.
`receive reimbursement from Aetna for the health care services provided.
`
`50.
`50.
`
`On or around January 20, 2016, NSPC sent Aetna a bill in the amount of
`On or around January 20, 2016, NSPC sent Aetna a bill in the amount of
`
`$25,200.00 for the medically necessary health care services provided. Pursuant to the terms of
`$25,200.00 for the medically necessary health care services provided. Pursuant to the terms of
`
`the relevant Aetna health plan documents and agreements and applicable law, Aetna was
`the relevant Aetna health plan documents and agreements and applicable law, Aetna was
`
`obligated to reimburse NSPC in full – or at the very least at a usual, customary, or reasonable
`obligated to reimburse NSPC in full — or at the very least at a usual, customary, or reasonable
`
`amount – for the medically necessary health care services provided to JA.
`amount — for the medically necessary health care services provided to JA.
`
`51.
`51.
`
`Recognizing NSPC’s status as an assigned beneficiary, Aetna and NSPC
`Recognizing NSPC's status as an assigned beneficiary, Aetna and NSPC
`
`communicated with each other numerous times – including on 1/20, 1/28, and 2/9/16 – at which
`communicated with each other numerous times — including on 1/20, 1/28, and 2/9/16 — at which
`
`times NSPC appealed to Aetna for additional payment. Not once during these communications
`times NSPC appealed to Aetna for additional payment. Not once during these communications
`
`did Aetna ever state it was not administering the health plan at issue, or state that the claim was
`did Aetna ever state it was not administering the health plan at issue, or state that the claim was
`
`covered by Medicare or federal employee health benefits (“FEHB”).
`covered by Medicare or federal employee health benefits ("FEHB").
`
`52.
`52.
`
`Aetna has failed and refused to reimburse NSPC in full – or at the very least at a
`Aetna has failed and refused to reimburse NSPC in full — or at the very least at a
`
`usual, customary, or reasonable amount – for the medically necessary health care services
`usual, customary, or reasonable amount — for the medically necessary health care services
`
`provided to JA. Indeed, NSPC has recieved no payment for its services.
`provided to JA. Indeed, NSPC has recieved no payment for its services.
`
`53.
`53.
`
`Upon information and belief, Aetna was obligated to pay at least 80% of the
`Upon information and belief, Aetna was obligated to pay at least 80% of the
`
`“recognized charge” on the claims presented, but failed to pay any amount despite the medical
`"recognized charge" on the claims presented, but failed to pay any amount despite the medical
`
`necessity of the services rendered.
`necessity of the services rendered.
`
`4197621v.8
`4197621v.8
`
`10
`10
`
`

`

`Case 2:19-cv-04817-DRH-ARL Document 5 Filed 08/30/19 Page 11 of 407 PageID #: 36
`
`54.
`54.
`
`Upon further information and belief, the “recognized charge” fo