Preview
F Superior Court of California
County of Butte
|
LAW OFFICES OF STEPHENSON, ACQUISTO & L
6/9/2021
COLMAN, INC.
JOY STEPHENSON-LAWS, ESQ. (SBN 113755) 5
RICHARD A. LOVICH, ESQ. (SBN. 113472) Deputy
KARLENE ROGERS-ABERMAN, ESQ. (SBN 237883)
DAVID F. MASTAN, ESQ. (SBN 152109)
SARKIS S. YERETSIAN, ESQ. (SBN. 327625)
303 N. Glenoaks Blvd., Suite 700
Burbank, CA 91502
Telephone: (818) 559-4477
Facsimile: (818) 559-5484
Attomeys for Plaintiff,
ENLOE MEDICAL CENTER
10
11
12 SUPERIOR COURT OF CALIFORNIA
13 FOR THE COUNTY OF BUITE
14 UNLIMITED JURISDICTION
15
16 ENLOE MEDICAL CENTER, a Case No.: 21CV01487
Califomia non-profit public benefit
17 corporation,
18 (COMPLAINT FOR DAMAGES
Plaintiff,
19 FOR:
VS.
20 1 BREACH OF IMPLIED-IN-
HEALTHSCOPE BENEFITS, INC. a FACT CONTRACT; AND
21
Delaware for-profit corporation; and
22 DOES 1 THROUGH 25, INCLUSIVE, 2. QUANTUM MERUIT
23 Defendants.
24
25
26
27
28
FC 28181 1 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
PARTIES
1 Plaintiff Enloe Medical Center (“ENLOE MEDICAL
CENTER”) is a 298 bed acute care hospital serving the health care needs of
Northem Califomia residents since 1913. It is a recognized Level II trauma center,
provides world class medical care, including cancer treatment, and is consistently
mentioned in any conversation of the outstanding healthcare providers nationally
and in the greater Sacramento
area. It is a public benefit corporation
organized and
existing pursuant to the laws of the State of Califomia, and maintains its principal
10 place of business in the City of Chico, County of Butte, State of Califomia.
11
12
2 Defendant Healthscope Benefits (hereinafter
“HEALTHSCOPE:’) is a for-profit corporation that does business in Califomia and]
13
is organized and existing pursuant to the laws of the State of Delaware.
14
Healthscope
has its principal place of business in the City of Little Rock, County
15
of Pulaski, State of Arkansas. Among other things, Healthscope sponsors and
16
administers health plans.
17
18
3 ENLOE MEDICAL CENTER is unaware of the true names and
19 capacities, whether corporate, associate, individual, partnership or otherwise of
20 defendants Does 1 through 25, inclusive, and therefore sues such defendants by
21 such fictitious names. ENLOE MEDICAL CENTER will seek leave of the Court
22 to amend this complaint to allege their true names and capacities when ascertained.
23
24 4. HEALTHSCOPE, and Does 1 through 25, inclusive, shall be
25 collectively referred to as "HEALTHSCOPE".
26
27 5, Defendants, and each of them, at all relevant times, have
28 transacted business in the State of Califomia. The violations alleged within this
FC 28181 2 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
complaint have been and are being carried out in the State of Califomia.
6. At all relevant times each of the defendants, including the
defendants named “Doe,” was and is the agent, employee, employer, joint
venturer, representative, alter ego, subsidiary, and/or partner of one or more of the
other defendants, and was, in performing the acts complained of herein, acting
within the scope of such agency, employment, joint venture, or partnership
authority, and/or is in some other way responsible for the acts of one or more of the
other defendants.
10
11 COMMON FACTUAL BACKGROUND
12
7, ENLOE MEDICAL CENTER, between the dates of May 8,
13
2019 through June 9, 2019, provided the patients set forth in Exhibit A! to this
14
Complaint and incorporated herein by this reference as though set forth in full,
15
medically necessary services. At all relevant times, the patients listed on ExhibitA
16
(“Patients") enrollees of HEALTHSCOPE’s health plan.
17
18
8. Where appropriate, ENLOE MEDICAL CENTER contacted
19
HEALTHSCOPE and/or its agents to ascertain whether or not HEALTHSCOPE or,
20 its principal was responsible for the costs associated with the medically necessary
21 services, supplies and/or equipment rendered to the Patients. In response,
22 HEALTHSCOPE’ agent verified to ENLOE MEDICAL CENTER the relevant
23 insurance verification and insurance coverage eligibility information for the
24 Patients under HEALTHSCOPE’ health plan.
25
26 1 ENLOE MEDICAL CENTER has limited the disclosure of patient identification information here pursuant to the
privacy provisions of the federal Health Insurance Portability & Accountability Act ("HIPAA"), 42 U.S.C. §§
27 1320(d) et seq., and the Califomia Constitution, art. 1, § 1.
28
FC 28181 3 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
9. ENLOE MEDICAL CENTER is informed and believes and
thereon alleges that at all relevant times, HEALTHSCOPE provided, sponsored,
administered, and/or paid for the health benefits plan of which the Patients were
enrollees.
10. There was no written contract or agreement between the parties
granting HEALTHSCOPE any discount from ENLOE MEDICAL CENTER’s
publicly published charge description master (“Chargemaster”’), which sets forth a
‘menu’ of prices for each item appearing on its bills, for the services rendered.
10 The Chargemaster is posted on the Office of Statewide Health Planning and
Development (“OSHPD”), a govemmental website. The charges posted on
11
OSHPD for the services, supplies and/or equipment rendered to the Patients
12
amounted to $124,349.50. HEALTHSCOPE to date has paid $22,672.78.
13
14
11. ENLOE MEDICAL CENTER timely and properly submittedto
15
HEALTHSCOPE, and/orits agent, at the address provided by HEALTHSCOPE its|
16
bill for the medically necessary services, supplies and/or equipment rendered to the}
17
Patients, for payment by HEALTHSCOPE.
18
19 12. ENLOE MEDICAL CENTER has now exhausted all available
20 administrative remedies to appeal HEALTHSCOPE’ refusal to pay the total
21 amount due for the medically
necessary care rendered
to the Patients.
22
23 13. Despite timely demand for full payment, HEALTHSCOPE
24 refused and continues to refuse to properly pay ENLOE MEDICAL CENTER for
25 the medically necessary services, supplies and/or equipment ENLOE MEDICAL
26 CENTER rendered to the Patients. As a result, ENLOE MEDICAL CENTER
27 suffered damages in an amount to be established at trial but no less than the sum of
28 $99,230.99, exclusive of interest.
FC 28181 4 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
FIRST CAUSE OF ACTION
(Breach of Implied-In-Fact Contract)
(Against Defendant HEA LTHSCOPE)
(and/or Does 1 through 25)
14. ENLOE MEDICAL CENTER incorporates by reference and re}
alleges paragraphs 1 through 13 here as though set forth in full.
10 15. Prior to the treatment rendered by ENLOE MEDICAL
11 CENTER, ENLOE MEDICAL CENTER and HEALTHSCOPE impliedly agreed.
and understood that ENLOE MEDICAL CENTER would render medically
12
necessary care to HEALTHSCOPE enrollees, submit bills for such care to
13
HEALTHSCOPE, and that HEALTHSCOPE would pay ENLOE MEDICAL
14
CENTER at the provider’ s reasonable and customary value of its posted charges
15
for the medically necessary services provided to the Patients.
16
17
16. Once ENLOE MEDICAL CENTER was made aware that:
18
HEALTHSCOPE was the proper payor, it contacted HEALTHSCOPE to notify it
19 of the Patients’ services. HEALTHSCOPE provided the relevant insurance
20 verification and insurance coverage eligibility conceming the Patients. Under
21 HEALTHSCOPE’s health plans, HEALTHSCOPE authorized ENLOE MEDICAL,
22 CENTER to provide care to the Patients.
23
24 17. On or about the time ENLOE MEDICAL CENTER admitted
25 the Patients, ENLOE MEDICAL CENTER and HEALTHSCOPE had entered into
26 an implied-in-fact contract as demonstrated by the actions and conduct of
27 HEALTHSCOPE. ENLOE MEDICAL CENTER alleges that HEALTHSCOPE
28 offered to reimburse ENLOE MEDICAL CENTER should ENLOE MEDICAL
FC 28181 5 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
CENTER provide medically necessary care to HEALTHSCOPE enrollees.
ENLOE MEDICAL CENTER accepted that offer and did in fact provide medically,
necessary care to HEALTHSCOPE enrollees. ENLOE MEDICAL CENTER
properly billed HEALTHSCOPE for the medically necessary services, and as
demonstrated by Exhibit A, HEALTHSCOPE did in fact actually reimburse
ENLOE MEDICAL CENTER for a portion of the services rendered in partial
compliance with the implied-in-fact contract. The dispute in this matter is not
whether HEALTHSCOPE should have paid ENLOE MEDICAL CENTER, but
rather as to the amount HEALTHSCOPE should have paid to ENLOE MEDICAL
CENTER for each of the Patients identified in Exhibit A.
10
11
18. ENLOE MEDICAL CENTER perfonmed all conditions
12
required on its part to be performed in accordance with the terms and conditions of
13
that implied-in-fact contract. ENLOE MEDICAL CENTER reasonably relied on
14
HEALTHSCOPE’ promises and conduct to pay for medical services and continued
15
treating the Patients in reliance on those promises and upon such conduct.
16
17
19. By way of its words and/or conduct, HEALTHSCOPE and/or
18
its agents acknowledged
the need for medical care for the Patients and requested
19 that ENLOE MEDICAL CENTER provide medically necessary services to the
20 Patients.
21
22 20. Since HEALTHSCOPE is a “health care service plan” as
23 defined in the Califomia Health and Safety Code, at all relevant times
24 HEALTHSCOPE
was under a statutory duty to pay for emergency services and
25 care provided
to its enrollees until each enrollee was stabilized
pursuant to
26 Califomia Health and Safety Code §1371.4(b). ENLOE MEDICAL CENTER
27 rendered medically necessary, emergency services, supplies and/or equipment to
28 various Patients from the time of the Patients’ admission, as set forth in Exhibit A,
FC 28181 6 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
to the time when each of the Patients’ conditions had sufficiently stabilized to
enable each of the Patients to be discharged or transferred.
21. ENLOE MEDICAL CENTER’s usual and customary total
billed charges for rendering the medically necessary care to the Patients amounted
to $124,349.50. HEALTHSCOPE to date has paid $22,672.78, leaving a balance
of $99,230.99.
22. ENLOE MEDICAL CENTER rendered all medically necessary
10 services to the Patient and performed all conditions, covenants, and promises
11 required on its part to be performed in accordance with the terms and conditions of
the above-described implied-in-fact contract.
12
13
23. HEALTHSCOPE breached the above-described implied-in-fact)
14
contract by underpaying ENLOE MEDICAL CENTER for the medically necessary,
15
services, supplies and/or equipment rendered or supplied to the Patients.
16
17
24. Asaresult of the breach of the implied-in-fact contract,
18
ENLOE MEDICAL CENTER suffered damages in an amount
to be established
at
19
trial but not less than $99,230.99, exclusive of interest.
20
21 SECOND CAUSE OF ACTION
22 (Quantum Meruit)
23 (Against defendant HEA LTHSCOPE)
24 (and/or including Does 1 through 25, inclusive)
25
26 25. ENLOE MEDICAL CENTER incorporate by reference and re-
27 alleges paragraphs 1 through 24 here as though set forth in full.
28
FC 28181 7 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
26. For the period of time between May 8, 2019 through June 9,
2019, inclusive, by its words and/or conduct, HEALTHSCOPE requested that
ENLOE MEDICAL CENTER provide the Patients set forth in ExhibitA with
medically necessary, emergency services, supplies and/or equipment.
27. Based upon HEALTHSCOPE’s and/or HEALTHSCOPE’s
enrollee’s express special request and insistence, ENLOE MEDICAL CENTER
rendered medical care to Patients as described herein. The usual and customary
value of the medical care so rendered was $124,349.50.
10
11 28. HEALTHSCOPE benefitted from ENLOE MEDICAL
CENTER’s provision of services because ENLOE MEDICAL CENTER’s
12
provision of services to HEALTHSCOPE’s members allowed HEALTHSCOPE to
13
discharge its contractual obligations to its members which arise from
14
HEALTHSCOPE’s collection of premiums from the patients.
15
16
29. Forrendering the medically necessary, emergency services,
17
supplies and/or equipment to the Patients, ENLOE MEDICAL CENTER expected
18
reimbursement at the reasonable and customary value of its charges.
19
20 30. As stated above, ENLOE MEDICAL CENTER’s publicly
21 published charges on OSHPD for the medically necessary services, supplies and/or|
22 equipment it rendered to the Patients set forth in ExhibitA was $124,349.50.
23
24 31. Within the past two years, ENLOE MEDICAL CENTER
25 demanded HEALTHSCOPE to pay for the medically necessary, emergency
26 services, supplies and/or equipment it rendered to the Patients but to date,
27 HEALTHSCOPE has only made payments in the amount of $22,672.78.
28
FC 28181 8 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
32. As aresult of the Defendants’ misconduct, ENLOE MEDICAL
CENTER have suffered damages in an amount to be proven established at trial
according to proof but not less than $99,230.99.
PRAYER FOR RELIEF
WHEREFORE, ENLOE MEDICAL CENTER prays for judgment as follows:
For the First Cause of Action:
1 for the principal sum to be established at trial but not less than
10
$99,230.99;
11
12 2 for interest
on such principal sum at the rate
of 15% per annum,
pursuant
to Cal. Health& Safety Code§ 1371; or, in the altemative, for interest
on
13
such principal sum at the rate of 10% per annum, pursuant
to Cal. Civ. Code§
14
3289;
15
16 For the Second Cause of Action:
17
3 for the principal sum to be established at trial but not less than
18
$99,230.99;
19
20 For All Causes of Action:
21 4. for all costs of suit incurred herein; and,
22
5, for such other and further relief as the Court deems just and
23
proper.
24
25 MH
26
27 MH
28
FC 28181 9 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
1 |! Dated: 9 June 2021
2 LAW OFFICES OF STEPHENSON,
ACQUISTO & COLMAN, INC.
3
4 Sarkis S Yeretsian
5
SARKIS S. YERETSIAN, ESQ
Attomeys for Plaintiff
ENLOE MEDICAL CENTER
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
FC 28181 - 10- COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM
MERUIT
10
11 EXHIBITA
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
FC 28181 -11- COMPLAINT FOR DAMAGES FOR: 1. BREACH OF
IMPLIED-IN-FACT CONTRACT; 2. QUANTUM.
MERUIT
ENLOE MEDICAL CENTER - COHASSET V. HEALTH SCOPE, HEALTHSCOPE BENEFITS
Exhibit A
FC 28181
No. Patient Initials File Number Admit Date Discharge Date Total Charges Underpaid
JH 50426822 5/8/2019 5/9/2019 $85,030.50. $72,801.78
2 J.H 50474937 5/8/2019 5/8/2019 $2,911.00 $2,377.41,
3 A.P. 50469863 6/9/2019 6/9/2019 $36,408.00 $24,051.80
$99,230.99
Preview
F Superior Court of California County of Butte | LAW OFFICES OF STEPHENSON, ACQUISTO & L 6/9/2021 COLMAN, INC. JOY STEPHENSON-LAWS, ESQ. (SBN 113755) 5 RICHARD A. LOVICH, ESQ. (SBN. 113472) Deputy KARLENE ROGERS-ABERMAN, ESQ. (SBN 237883) DAVID F. MASTAN, ESQ. (SBN 152109) SARKIS S. YERETSIAN, ESQ. (SBN. 327625) 303 N. Glenoaks Blvd., Suite 700 Burbank, CA 91502 Telephone: (818) 559-4477 Facsimile: (818) 559-5484 Attomeys for Plaintiff, ENLOE MEDICAL CENTER 10 11 12 SUPERIOR COURT OF CALIFORNIA 13 FOR THE COUNTY OF BUITE 14 UNLIMITED JURISDICTION 15 16 ENLOE MEDICAL CENTER, a Case No.: 21CV01487 Califomia non-profit public benefit 17 corporation, 18 (COMPLAINT FOR DAMAGES Plaintiff, 19 FOR: VS. 20 1 BREACH OF IMPLIED-IN- HEALTHSCOPE BENEFITS, INC. a FACT CONTRACT; AND 21 Delaware for-profit corporation; and 22 DOES 1 THROUGH 25, INCLUSIVE, 2. QUANTUM MERUIT 23 Defendants. 24 25 26 27 28 FC 28181 1 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT PARTIES 1 Plaintiff Enloe Medical Center (“ENLOE MEDICAL CENTER”) is a 298 bed acute care hospital serving the health care needs of Northem Califomia residents since 1913. It is a recognized Level II trauma center, provides world class medical care, including cancer treatment, and is consistently mentioned in any conversation of the outstanding healthcare providers nationally and in the greater Sacramento area. It is a public benefit corporation organized and existing pursuant to the laws of the State of Califomia, and maintains its principal 10 place of business in the City of Chico, County of Butte, State of Califomia. 11 12 2 Defendant Healthscope Benefits (hereinafter “HEALTHSCOPE:’) is a for-profit corporation that does business in Califomia and] 13 is organized and existing pursuant to the laws of the State of Delaware. 14 Healthscope has its principal place of business in the City of Little Rock, County 15 of Pulaski, State of Arkansas. Among other things, Healthscope sponsors and 16 administers health plans. 17 18 3 ENLOE MEDICAL CENTER is unaware of the true names and 19 capacities, whether corporate, associate, individual, partnership or otherwise of 20 defendants Does 1 through 25, inclusive, and therefore sues such defendants by 21 such fictitious names. ENLOE MEDICAL CENTER will seek leave of the Court 22 to amend this complaint to allege their true names and capacities when ascertained. 23 24 4. HEALTHSCOPE, and Does 1 through 25, inclusive, shall be 25 collectively referred to as "HEALTHSCOPE". 26 27 5, Defendants, and each of them, at all relevant times, have 28 transacted business in the State of Califomia. The violations alleged within this FC 28181 2 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT complaint have been and are being carried out in the State of Califomia. 6. At all relevant times each of the defendants, including the defendants named “Doe,” was and is the agent, employee, employer, joint venturer, representative, alter ego, subsidiary, and/or partner of one or more of the other defendants, and was, in performing the acts complained of herein, acting within the scope of such agency, employment, joint venture, or partnership authority, and/or is in some other way responsible for the acts of one or more of the other defendants. 10 11 COMMON FACTUAL BACKGROUND 12 7, ENLOE MEDICAL CENTER, between the dates of May 8, 13 2019 through June 9, 2019, provided the patients set forth in Exhibit A! to this 14 Complaint and incorporated herein by this reference as though set forth in full, 15 medically necessary services. At all relevant times, the patients listed on ExhibitA 16 (“Patients") enrollees of HEALTHSCOPE’s health plan. 17 18 8. Where appropriate, ENLOE MEDICAL CENTER contacted 19 HEALTHSCOPE and/or its agents to ascertain whether or not HEALTHSCOPE or, 20 its principal was responsible for the costs associated with the medically necessary 21 services, supplies and/or equipment rendered to the Patients. In response, 22 HEALTHSCOPE’ agent verified to ENLOE MEDICAL CENTER the relevant 23 insurance verification and insurance coverage eligibility information for the 24 Patients under HEALTHSCOPE’ health plan. 25 26 1 ENLOE MEDICAL CENTER has limited the disclosure of patient identification information here pursuant to the privacy provisions of the federal Health Insurance Portability & Accountability Act ("HIPAA"), 42 U.S.C. §§ 27 1320(d) et seq., and the Califomia Constitution, art. 1, § 1. 28 FC 28181 3 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT 9. ENLOE MEDICAL CENTER is informed and believes and thereon alleges that at all relevant times, HEALTHSCOPE provided, sponsored, administered, and/or paid for the health benefits plan of which the Patients were enrollees. 10. There was no written contract or agreement between the parties granting HEALTHSCOPE any discount from ENLOE MEDICAL CENTER’s publicly published charge description master (“Chargemaster”’), which sets forth a ‘menu’ of prices for each item appearing on its bills, for the services rendered. 10 The Chargemaster is posted on the Office of Statewide Health Planning and Development (“OSHPD”), a govemmental website. The charges posted on 11 OSHPD for the services, supplies and/or equipment rendered to the Patients 12 amounted to $124,349.50. HEALTHSCOPE to date has paid $22,672.78. 13 14 11. ENLOE MEDICAL CENTER timely and properly submittedto 15 HEALTHSCOPE, and/orits agent, at the address provided by HEALTHSCOPE its| 16 bill for the medically necessary services, supplies and/or equipment rendered to the} 17 Patients, for payment by HEALTHSCOPE. 18 19 12. ENLOE MEDICAL CENTER has now exhausted all available 20 administrative remedies to appeal HEALTHSCOPE’ refusal to pay the total 21 amount due for the medically necessary care rendered to the Patients. 22 23 13. Despite timely demand for full payment, HEALTHSCOPE 24 refused and continues to refuse to properly pay ENLOE MEDICAL CENTER for 25 the medically necessary services, supplies and/or equipment ENLOE MEDICAL 26 CENTER rendered to the Patients. As a result, ENLOE MEDICAL CENTER 27 suffered damages in an amount to be established at trial but no less than the sum of 28 $99,230.99, exclusive of interest. FC 28181 4 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT FIRST CAUSE OF ACTION (Breach of Implied-In-Fact Contract) (Against Defendant HEA LTHSCOPE) (and/or Does 1 through 25) 14. ENLOE MEDICAL CENTER incorporates by reference and re} alleges paragraphs 1 through 13 here as though set forth in full. 10 15. Prior to the treatment rendered by ENLOE MEDICAL 11 CENTER, ENLOE MEDICAL CENTER and HEALTHSCOPE impliedly agreed. and understood that ENLOE MEDICAL CENTER would render medically 12 necessary care to HEALTHSCOPE enrollees, submit bills for such care to 13 HEALTHSCOPE, and that HEALTHSCOPE would pay ENLOE MEDICAL 14 CENTER at the provider’ s reasonable and customary value of its posted charges 15 for the medically necessary services provided to the Patients. 16 17 16. Once ENLOE MEDICAL CENTER was made aware that: 18 HEALTHSCOPE was the proper payor, it contacted HEALTHSCOPE to notify it 19 of the Patients’ services. HEALTHSCOPE provided the relevant insurance 20 verification and insurance coverage eligibility conceming the Patients. Under 21 HEALTHSCOPE’s health plans, HEALTHSCOPE authorized ENLOE MEDICAL, 22 CENTER to provide care to the Patients. 23 24 17. On or about the time ENLOE MEDICAL CENTER admitted 25 the Patients, ENLOE MEDICAL CENTER and HEALTHSCOPE had entered into 26 an implied-in-fact contract as demonstrated by the actions and conduct of 27 HEALTHSCOPE. ENLOE MEDICAL CENTER alleges that HEALTHSCOPE 28 offered to reimburse ENLOE MEDICAL CENTER should ENLOE MEDICAL FC 28181 5 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT CENTER provide medically necessary care to HEALTHSCOPE enrollees. ENLOE MEDICAL CENTER accepted that offer and did in fact provide medically, necessary care to HEALTHSCOPE enrollees. ENLOE MEDICAL CENTER properly billed HEALTHSCOPE for the medically necessary services, and as demonstrated by Exhibit A, HEALTHSCOPE did in fact actually reimburse ENLOE MEDICAL CENTER for a portion of the services rendered in partial compliance with the implied-in-fact contract. The dispute in this matter is not whether HEALTHSCOPE should have paid ENLOE MEDICAL CENTER, but rather as to the amount HEALTHSCOPE should have paid to ENLOE MEDICAL CENTER for each of the Patients identified in Exhibit A. 10 11 18. ENLOE MEDICAL CENTER perfonmed all conditions 12 required on its part to be performed in accordance with the terms and conditions of 13 that implied-in-fact contract. ENLOE MEDICAL CENTER reasonably relied on 14 HEALTHSCOPE’ promises and conduct to pay for medical services and continued 15 treating the Patients in reliance on those promises and upon such conduct. 16 17 19. By way of its words and/or conduct, HEALTHSCOPE and/or 18 its agents acknowledged the need for medical care for the Patients and requested 19 that ENLOE MEDICAL CENTER provide medically necessary services to the 20 Patients. 21 22 20. Since HEALTHSCOPE is a “health care service plan” as 23 defined in the Califomia Health and Safety Code, at all relevant times 24 HEALTHSCOPE was under a statutory duty to pay for emergency services and 25 care provided to its enrollees until each enrollee was stabilized pursuant to 26 Califomia Health and Safety Code §1371.4(b). ENLOE MEDICAL CENTER 27 rendered medically necessary, emergency services, supplies and/or equipment to 28 various Patients from the time of the Patients’ admission, as set forth in Exhibit A, FC 28181 6 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT to the time when each of the Patients’ conditions had sufficiently stabilized to enable each of the Patients to be discharged or transferred. 21. ENLOE MEDICAL CENTER’s usual and customary total billed charges for rendering the medically necessary care to the Patients amounted to $124,349.50. HEALTHSCOPE to date has paid $22,672.78, leaving a balance of $99,230.99. 22. ENLOE MEDICAL CENTER rendered all medically necessary 10 services to the Patient and performed all conditions, covenants, and promises 11 required on its part to be performed in accordance with the terms and conditions of the above-described implied-in-fact contract. 12 13 23. HEALTHSCOPE breached the above-described implied-in-fact) 14 contract by underpaying ENLOE MEDICAL CENTER for the medically necessary, 15 services, supplies and/or equipment rendered or supplied to the Patients. 16 17 24. Asaresult of the breach of the implied-in-fact contract, 18 ENLOE MEDICAL CENTER suffered damages in an amount to be established at 19 trial but not less than $99,230.99, exclusive of interest. 20 21 SECOND CAUSE OF ACTION 22 (Quantum Meruit) 23 (Against defendant HEA LTHSCOPE) 24 (and/or including Does 1 through 25, inclusive) 25 26 25. ENLOE MEDICAL CENTER incorporate by reference and re- 27 alleges paragraphs 1 through 24 here as though set forth in full. 28 FC 28181 7 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT 26. For the period of time between May 8, 2019 through June 9, 2019, inclusive, by its words and/or conduct, HEALTHSCOPE requested that ENLOE MEDICAL CENTER provide the Patients set forth in ExhibitA with medically necessary, emergency services, supplies and/or equipment. 27. Based upon HEALTHSCOPE’s and/or HEALTHSCOPE’s enrollee’s express special request and insistence, ENLOE MEDICAL CENTER rendered medical care to Patients as described herein. The usual and customary value of the medical care so rendered was $124,349.50. 10 11 28. HEALTHSCOPE benefitted from ENLOE MEDICAL CENTER’s provision of services because ENLOE MEDICAL CENTER’s 12 provision of services to HEALTHSCOPE’s members allowed HEALTHSCOPE to 13 discharge its contractual obligations to its members which arise from 14 HEALTHSCOPE’s collection of premiums from the patients. 15 16 29. Forrendering the medically necessary, emergency services, 17 supplies and/or equipment to the Patients, ENLOE MEDICAL CENTER expected 18 reimbursement at the reasonable and customary value of its charges. 19 20 30. As stated above, ENLOE MEDICAL CENTER’s publicly 21 published charges on OSHPD for the medically necessary services, supplies and/or| 22 equipment it rendered to the Patients set forth in ExhibitA was $124,349.50. 23 24 31. Within the past two years, ENLOE MEDICAL CENTER 25 demanded HEALTHSCOPE to pay for the medically necessary, emergency 26 services, supplies and/or equipment it rendered to the Patients but to date, 27 HEALTHSCOPE has only made payments in the amount of $22,672.78. 28 FC 28181 8 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT 32. As aresult of the Defendants’ misconduct, ENLOE MEDICAL CENTER have suffered damages in an amount to be proven established at trial according to proof but not less than $99,230.99. PRAYER FOR RELIEF WHEREFORE, ENLOE MEDICAL CENTER prays for judgment as follows: For the First Cause of Action: 1 for the principal sum to be established at trial but not less than 10 $99,230.99; 11 12 2 for interest on such principal sum at the rate of 15% per annum, pursuant to Cal. Health& Safety Code§ 1371; or, in the altemative, for interest on 13 such principal sum at the rate of 10% per annum, pursuant to Cal. Civ. Code§ 14 3289; 15 16 For the Second Cause of Action: 17 3 for the principal sum to be established at trial but not less than 18 $99,230.99; 19 20 For All Causes of Action: 21 4. for all costs of suit incurred herein; and, 22 5, for such other and further relief as the Court deems just and 23 proper. 24 25 MH 26 27 MH 28 FC 28181 9 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT 1 |! Dated: 9 June 2021 2 LAW OFFICES OF STEPHENSON, ACQUISTO & COLMAN, INC. 3 4 Sarkis S Yeretsian 5 SARKIS S. YERETSIAN, ESQ Attomeys for Plaintiff ENLOE MEDICAL CENTER 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 FC 28181 - 10- COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM MERUIT 10 11 EXHIBITA 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 FC 28181 -11- COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED-IN-FACT CONTRACT; 2. QUANTUM. MERUIT ENLOE MEDICAL CENTER - COHASSET V. HEALTH SCOPE, HEALTHSCOPE BENEFITS Exhibit A FC 28181 No. Patient Initials File Number Admit Date Discharge Date Total Charges Underpaid JH 50426822 5/8/2019 5/9/2019 $85,030.50. $72,801.78 2 J.H 50474937 5/8/2019 5/8/2019 $2,911.00 $2,377.41, 3 A.P. 50469863 6/9/2019 6/9/2019 $36,408.00 $24,051.80 $99,230.99