On November 22, 2023 a
Hearing
was filed
involving a dispute between
Nuvance Health, Inc.,
and
Ralph Espinal,
Renee Ann Bishop,
for C40 - Contracts - Collections
in the District Court of Fairfield County.
Preview
DOC. NO.: DBD-CV23-6048265-S : SUPERIOR COURT
NUVANCE HEALTH, INC. : JUDICIAL DISTRICT OF DANBURY
Vv.
ESPINAL, RALPH ET AL. : MARCH 22, 2024
AFFIDAVIT RE: INTEREST
The undersigned represents:
1. That Iam counsel for the plaintiff in the matter of Nuvance Health, Inc. v. Ralph Espinal, Doc. No. DBD-
CV23-6048265-S, pending in Danbury Superior Court.
2. The plaintiff claims damages in the amount of $26,349.94 for hospital services rendered by Nuvance Health,
Inc. member New Milford Hospital to defendant Ralph Espinal. (A true copy of the original billing invoice
(redacted per § 4-7) is attached hereto.)
3. Pursuant to Gen. Stat. § 37-3a the plaintiff claims interest on the $26,349.94 balance due at two and one-half
percent (2.5%) per annum in the amount of $1,214.56.
4. That the $1,214.56 in statutory interest is calculated as follows: interest on the principal $26,349.94 at 2.5%
per annum based upon a 360-day year @ 1.8292 per diem starting 30 days after hospital discharge date of April
29, 2022, to March 22, 2024, the date scheduled for a hearing in damages, less any payments against principal
balance due.
Affiant so swears,
V. Michael imko, Jr.
Juris #308789
STATE OF CONNECTICUT )
) ss: SEYMOUR
COUNTY OF NEW HAVEN )
Personally appeared V. Michael Simko, Jr. before me who swore to the truth of the foregoing
statements this _Z2¢/ day of March 2024.
LH
Jo: T. Poulsen
COfnmissioner of the Superior Court
BILLING INVOICE
Nuvance Heaith Fs: ury and New M
PO Box 21274
New York, NY 100871274
Pt Name: RALPH ESPINAL
Attending Physician: Alla Rudinskaya Statement Number: 36900009
Principal Diagnosis: K51.80 Account Number: 8308
Provider: DH Danbury Hosp BU Enc. ID / ECD ID: 9922
Provider Tax ID #: 060646597 Claim ID: 0101
Bill Date: 06/07/2023
Birth Date: 1978
Detail for: OP Serial Weekly Services Infu/Chemo/Rad Onc 64/29/2022 —
04/29/2022
Date Rev Cd Sve Cd Description Qty Amount ($)
CHARGES
04/29/2022 250 J7050 SODIUM CHLORIDE 0.9% 250ML 99.23
04/29/2022 636 J3380 VEDOLIZUMAB IMG INJ 300 24,657.42
04/29/2022 250 J3490 SODIUM CHLORIDE 0.9% SOML 116.87
04/29/2022 250 ACETAMINOPHEN 325MG TAB 221
04/29/2022 270 IV INS PERIPH SUPPLY 124.00
04/29/2022 335 96413 CHEMO IV INFUSION INITIAL HR 1,348.00
04/29/2022 250 Q0163 DIPHENHYDRAMINE S0MG CAP 2.21
Total Room/Bed Charges $ 0.00
Total Other Charges $26,349.94
Total Charges $ 26,349.94
PAYMENTS/ADJUSTMENTS
10/14/2022 Anthem Ins Contractual Adj -14,392.86
01/27/2023 Anthem Manual Contractual Adjustment 14,392.86
Total Insurance Payments $ 0.00
Total Insurance Adjustments $ 0.00
Thank you for selecting our hospital for your health care needs.
Financial Coverage:
Nuvance Health
If you provided us with your insurance information, those charges have been
submitted to the following insurance plan(s). If this information is not
20 Stony Hill
Bethel CT 068011040
accurate, please contact Client Service to provide updated information
immediately. Thank you.
Priority Plan Name Policy # Subscriber
1 Anthem Cen Prf PPO RENEE ANN ESPINAL
8001
ADDRESS SERVICE REQUESTED
RALPH ESPINAL
16 REVERE ROAD
Guarantor: RAEPH ESPINAL
NEW MILFORD CT 06776
Nuvance Health Danbury and New Milford
PO Box 21274
New York, NY 100871274
Pt Name: RALPH ESPINAL
Attending Physician: Alla Rudinskaya Statement Number: 36900009
Principal Diagnosis: K51.80 Account Number: 8308
Provider: DH Danbury Hosp BU Enc. ID / ECD ID: 39922
Provider Tax ID #: 060646597 Claim ID: 0101
Bill Date: 06/07/2023
Birth Date: /1978
Detail for: OP Serialjgekly Services Infu/Chemo/Rad Onc
04/29/2022 — 04/29/2822
(Continued)
Total Insurance Payments / Adjustments $0.00
Total Guarantor Payments $0.00
Total Guarantor Adjustments $ 0.00
Total Guarantor Payments / Adjustments $0.00
TOTAL BALANCE DUE $ 26,349.94
Page 2 of 2
Preview
DOC. NO.: DBD-CV23-6048265-S : SUPERIOR COURT NUVANCE HEALTH, INC. : JUDICIAL DISTRICT OF DANBURY Vv. ESPINAL, RALPH ET AL. : MARCH 22, 2024 AFFIDAVIT RE: INTEREST The undersigned represents: 1. That Iam counsel for the plaintiff in the matter of Nuvance Health, Inc. v. Ralph Espinal, Doc. No. DBD- CV23-6048265-S, pending in Danbury Superior Court. 2. The plaintiff claims damages in the amount of $26,349.94 for hospital services rendered by Nuvance Health, Inc. member New Milford Hospital to defendant Ralph Espinal. (A true copy of the original billing invoice (redacted per § 4-7) is attached hereto.) 3. Pursuant to Gen. Stat. § 37-3a the plaintiff claims interest on the $26,349.94 balance due at two and one-half percent (2.5%) per annum in the amount of $1,214.56. 4. That the $1,214.56 in statutory interest is calculated as follows: interest on the principal $26,349.94 at 2.5% per annum based upon a 360-day year @ 1.8292 per diem starting 30 days after hospital discharge date of April 29, 2022, to March 22, 2024, the date scheduled for a hearing in damages, less any payments against principal balance due. Affiant so swears, V. Michael imko, Jr. Juris #308789 STATE OF CONNECTICUT ) ) ss: SEYMOUR COUNTY OF NEW HAVEN ) Personally appeared V. Michael Simko, Jr. before me who swore to the truth of the foregoing statements this _Z2¢/ day of March 2024. LH Jo: T. Poulsen COfnmissioner of the Superior Court BILLING INVOICE Nuvance Heaith Fs: ury and New M PO Box 21274 New York, NY 100871274 Pt Name: RALPH ESPINAL Attending Physician: Alla Rudinskaya Statement Number: 36900009 Principal Diagnosis: K51.80 Account Number: 8308 Provider: DH Danbury Hosp BU Enc. ID / ECD ID: 9922 Provider Tax ID #: 060646597 Claim ID: 0101 Bill Date: 06/07/2023 Birth Date: 1978 Detail for: OP Serial Weekly Services Infu/Chemo/Rad Onc 64/29/2022 — 04/29/2022 Date Rev Cd Sve Cd Description Qty Amount ($) CHARGES 04/29/2022 250 J7050 SODIUM CHLORIDE 0.9% 250ML 99.23 04/29/2022 636 J3380 VEDOLIZUMAB IMG INJ 300 24,657.42 04/29/2022 250 J3490 SODIUM CHLORIDE 0.9% SOML 116.87 04/29/2022 250 ACETAMINOPHEN 325MG TAB 221 04/29/2022 270 IV INS PERIPH SUPPLY 124.00 04/29/2022 335 96413 CHEMO IV INFUSION INITIAL HR 1,348.00 04/29/2022 250 Q0163 DIPHENHYDRAMINE S0MG CAP 2.21 Total Room/Bed Charges $ 0.00 Total Other Charges $26,349.94 Total Charges $ 26,349.94 PAYMENTS/ADJUSTMENTS 10/14/2022 Anthem Ins Contractual Adj -14,392.86 01/27/2023 Anthem Manual Contractual Adjustment 14,392.86 Total Insurance Payments $ 0.00 Total Insurance Adjustments $ 0.00 Thank you for selecting our hospital for your health care needs. Financial Coverage: Nuvance Health If you provided us with your insurance information, those charges have been submitted to the following insurance plan(s). If this information is not 20 Stony Hill Bethel CT 068011040 accurate, please contact Client Service to provide updated information immediately. Thank you. Priority Plan Name Policy # Subscriber 1 Anthem Cen Prf PPO RENEE ANN ESPINAL 8001 ADDRESS SERVICE REQUESTED RALPH ESPINAL 16 REVERE ROAD Guarantor: RAEPH ESPINAL NEW MILFORD CT 06776 Nuvance Health Danbury and New Milford PO Box 21274 New York, NY 100871274 Pt Name: RALPH ESPINAL Attending Physician: Alla Rudinskaya Statement Number: 36900009 Principal Diagnosis: K51.80 Account Number: 8308 Provider: DH Danbury Hosp BU Enc. ID / ECD ID: 39922 Provider Tax ID #: 060646597 Claim ID: 0101 Bill Date: 06/07/2023 Birth Date: /1978 Detail for: OP Serialjgekly Services Infu/Chemo/Rad Onc 04/29/2022 — 04/29/2822 (Continued) Total Insurance Payments / Adjustments $0.00 Total Guarantor Payments $0.00 Total Guarantor Adjustments $ 0.00 Total Guarantor Payments / Adjustments $0.00 TOTAL BALANCE DUE $ 26,349.94 Page 2 of 2