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Filing # 131905985 E-Filed 08/03/2021 10:01:49 AM
IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT
IN AND FOR BREVARD COUNTY, FLORIDA
CIVIL DIVISION
CASE NO.:
SURGERY CENTER OF VIERA, LLC,
Plaintiff,
v.
CIGNA HEALTH AND LIFE INSURANCE COMPANY,
HARRIS CORPORATION GROUP INSURANCE PLAN,
and HARRIS CORPORATION,
Defendants.
COMPLAINT
Plaintiff, Surgery Center of Viera, LLC (“SCV”), as medical provider, authorized
tepresentative, and assignee of patient / insured, D.B, sues Defendants, Cigna Health and Life
Insurance Company (“Cigna”), Harris Corporation Group Insurance Plan (the “Plan”), and
Harris Corporation (“Harris”),':?*> as follows:
1 Upon information and belief, in the summer of 2019, Harris Corporation, a Delaware corporation, became
known as (or merged with) L3 Harris Technologies, Inc., a Delaware corporation. But, as discussed below, the
subject medical procedure occurred on January 23, 2018, so this Complaint involves the parties and Plan
document in existence at that time.
? The Plan document is attached hereto as Exhibit A and fully incorporated herein by reference, which such Plan
document was tendered by Cigna to SCV under letters dated January 27, 2020, and February 5, 2020. Upon
information and belief, the Plan is self-funded; but, if discovery reveals the Plan was / is fully-insured (as opposed.
to self-funded), the Harris Defendants would not need to be part of the benefits amount dispute (Counts I-IID;
i.e., could be dismissed from this action without prejudice.
3 It would appear from Exhibit A that the name of the Plan is Harris Medical Plan, see, e.g., Ex. A at IV-2 (...
this description of the Harris Medical Plan...”), but we have been advised before by these same Defendants that
Harris Corporation Group Insurance Plan is the proper name of the Plan.
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXNATURE OF THE ACTION, PARTIES,
JURISDICTION, AND VENUE
1. This action arises (Counts I-III), under state law for Defendants’ wrongful,
unsubstantiated underpayment of monies owed to SCV for medical services SCV provided to
the patient / insured, D.B., on January 23, 2018, which such causes of action have absolutely
nothing to do with “right of payment” / coverage (i.e., have everything to do with “rate of
payment” / benefits underpayment) and which such causes of action have to do with third-
party re-pricing contracts separate and distinct from the insurance policy / Plan document.*
2. At all material times, SCV was a medical provider and a Florida limited
liability company with its citizenship (i.e., principal place of business / “nerve center”) in
Viera, Florida, Brevard County. SCV is sui juris in all respects. SCV’s members are as
follows: (a) Dr. Ara Deukmedjian, domiciled in Brevard County, Florida, (b) Sun
Deukmedjian, domiciled in Brevard County, Florida, and (c) Dr. Bharat Patel, domiciled in
Brevard County, Florida. At all material times, SCV was the authorized representative of D.B.
with an assignment of benefits as well,> having provided subject medical services to D.B. for
which a proper amount of compensation (Counts I-III) was / is due and owing. And, again,
Defendants honored such authorized representative and assignee capacities by, for examples,
carrying out pre-suit appeals with SCV and tendering partial claim payments directly to SCV.
3. Atall material times, Cigna was an insurance company incorporated in the State
of Connecticut and engaged in the business of selling and / or administering health insurance
4 If discovery reveals that Defendants’ purported administrative record production (under Cigna letters dated
January 27, 2020, and February 5, 2020) was / is not complete, SCV reserves the right to amend this Complaint.
> All germane authorization and / or assignment paperwork in SCV’s possession is attached hereto as Exhibit B
(in redacted form) and incorporated fully herein by reference.
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXand / or deciding health insurance claims (i.e., claim administering). Upon information and
belief, Cigna’s principal place of business is also in the State of Connecticut.
4. At all material times, Harris Corporation (and L3 Harris Technologies, Inc.,
for that matter at non-material times, see n. 1, supra), was a technology company incorporated
in the State of Delaware and engaged (in pertinent part here) in the administration and / or
sponsorship of the Plan. Upon information and belief, Harris Corporation’s principal place of
business is in the State of Florida. Upon information and belief, the Plan is not separate and
distinct from Harris (at least not with respect to jurisdictional citizenship); i.e., would share the
same state of incorporation and principal place of business information.
5. This Court has jurisdiction over this matter pursuant to Section 26.012 of the
Florida statutes, as the amount in controversy exceeds the sum of $30,000.00, exclusive of
attorneys’ fees, interest, and costs.
6. Venue is proper in this Court pursuant to Section 47.011 of the Florida Statutes
because, for examples, (a) a substantial part of the events or omissions giving rise to the
subject action occurred in this jurisdiction, namely the subject medical procedure and
Defendants’ underpayment of the subject insurance claim both at the initial claim and
subsequent pre-suit appeal stages (Counts I-III), and (b) the Defendants conduct business in this
jurisdiction.
7. All conditions precedent to the institution of this action (e.g., administrative pre-
suit appeals) have occurred, been performed, been waived, or were futile.
COMMON ALLEGATIONS
8. The patient’s Member I.D. number was / is 000211169 01, the assigned claim
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXteference number was / is 9431803493452, the patient account number was / is 000200012804,
and the authorization code (discussed again below) was / is B44NSKK1. Again, a copy of the
insuring agreement (which is separate and distinct from the re-pricing contracts / agreements at
issue in this lawsuit, see Exhibit C incorporated fully herein by reference, and / or whatever
mystery re-pricing contract / agreement / formula / program that Defendants implemented in
arriving at the rate of payment furnished here) is attached as Exhibit A and incorporated fully
herein by reference.
9. At all material times, D.B. was covered (i.e., coverage is not an issue here) by
the Plan as evidenced by several things, with examples now discussed (and more discussed
below).
a. If D.B. was not an eligible / covered insured, the subject claim would not have
been paid by Defendants in any amount, and this eligibility and claim payment
correlation reality is stated in the pre-authorization paperwork discussed below
and attached as Exhibit D. Exhibit D is incorporated fully herein by reference.
b. Ifthe subject surgery (which such surgery was broken down by codes found in
the HCFA found in SCV’s initial claim submission packet) had not been
covered,° the subject claim would not have been paid by Defendants in any
amount. Regarding coverage of the subject HCFA codes, Defendants’ EOBs
furnished by Cigna (further discussed below) are attached as Exhibit F and
evidence Defendants’ coverage decision. Exhibit F (made up of EOBs dated
© The HFCA form that was part of SCV’s thirteen-page claim submission package to Defendants, which such
claim submission package is noted below, is attached as Exhibit E. This HCFA exhibit is incorporated fully
herein by reference.
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXMarch 19, 2018, and October 31, 2018) is incorporated fully herein by
reference. And as one can plainly see from the Cigna-issued EOBs, Defendants
unilaterally re-priced the subject claim (somehow) and did not deny any aspects
of the claim in dispute here on coverage grounds (e.g., medical necessity,
experimental / investigational).’ To this day, we really have no idea how
Defendants came up with payments totaling $38,967.90 (on a billed amount of
$258,200.00, see Ex. E, or $246,328.00 when the $11,818.00 waiver discussed
in footnote 7 is taken into consideration) because at every turn (SCV’s requests
and undersigned counsel’s requests), Defendants have secreted how they came
up with $38,967.90; i.e., have never substantiated their determination that
$38,967.90 was a “usual, customary, reasonable” (“UCR”) amount (or the
“maximum reimbursable charge,” “MRC”) of payment for the subject
procedure. “Unilaterally” because applicable re-pricing contracts (that SCV
had actually agreed to, unlike the unagreed to mystery Defendants’ re-pricing
contract / agreement / formula / program) were already in place (see Ex. C).
Again, Plaintiff presently does not possess the paperwork associated with the
mystery Defendants’ re-pricing formula because Defendants have wrongly
secreted this paperwork (the very paperwork that would evidence how on earth
Defendants came up with their unreasonably low rate of payment) from SCV
7 “In dispute here” because SCV hereby forgoes any effort to obtain payment for the four Al codes identified on
the October 31, 2018, EOB (see Ex. F) totaling $11,818.00. This waiver is done in the spirit of compromise where
none should be required (because it was improper for Defendants to deny the four Al line-items) in order to
legally streamline this action (not turn this matter into a “right of payment” dispute).
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXin their perpetual refusal to substantiate the unjustifiably low rate of payment
force-fed to SCV here. But, as with the re-pricing contracts (Ex. C) that SCV
maintains should apply here in determining the proper rate of payment, the
mystery Defendants’ re-pricing contract / agreement / formula / program
unilaterally implemented by Defendants in arriving at the disputed claim
payment amount is also separate and distinct from the insurance policy / Plan
document (Ex. A). Meaning, there is absolutely no “relation to” defensive
ERISA preemption at play with a pricing dispute of this nature predicated on
re-pricing contracts standing alone from Exhibit A.
In sum, as evidenced by the variety of things noted in this averment, this action has
nothing to do with coverage (i.e., “right of payment”), it has everything to do with the amount
Defendants paid out (i.e., “rate of payment”) on covered HCFA codes based on a mystery
Defendants’ re-pricing contract / formula / program separate and distinct from the Plan
insurance document (Exhibit A). In other words, the mystery Defendants’ re-pricing contract /
formula / program that Defendants used in re-pricing the subject claim and the re-pricing
contracts / agreements (Ex. C) that SCV contends should have been used do not “relate to” the
Plan document (Ex. A); i.e., resolution of Counts I-III will not relate to (at least not beyond a
fleeting reference to, at most) the Plan document (Ex. A). Once more, “relation to” defensive
ERISA preemption simply does not apply here in relation to Counts I-III. And as many Courts
(several in this jurisdiction, to boot) have found, complete preemption most definitely does not
apply to cases of this ilk.
10. The fact that this dispute has nothing to do with coverage (i.e., has everything
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXto do with pricing / rate of payment) is further evidenced by Defendants’ pre-surgery
authorization paperwork (see Ex. D). The pre-surgery authorization paperwork (Ex. D) and
process is designed to put coverage (but not the eventual amount of claim payment) to rest,
which, as discussed above (and as evidenced by Ex. D) is what happened — Defendants deemed
the subject procedure medically necessary (which such medical necessity would relate to
coverage), other than the four HCFA line-items that SCV is not pursuing here. See n. 7, supra.
Exhibit D is incorporated fully herein by reference.®
11. At all material times leading up to the subject medical services received from
SCV, D.B. suffered from chronic lumbar pain with radiculopathy. D.B. tried alternative,
conservative management treatments, which failed and surgical treatment was deemed
medically necessary by both SCV (as evidenced by, for examples, the “operative note,” “history
and physical,” and “letter of medical necessity for surgery” found in SCV’s claim submission
package but not placed into the public domain at this juncture by way of Complaint exhibit due
to SCV’s concern with preserving D.B.’s privacy rights and not turning an initial pleading into
a complete evidence dump) and Defendants (as evidenced by, for example, the pre-
authorization paperwork attached as Exhibit D, which such pre-authorization paperwork was
also included in SCV’s claim submission package). So, on January 23, 2018, SCV operated on
D.B. to remedy the medical conditions.
12. By facsimile dated January 22, 2018, and prior to the subject procedure, Cigna
8 For what it is worth, to the point made in footnote 7 above about Defendants’ eventual denial of four HCFA
line-items being wrong, as one can see from Exhibit D, Cigna had approved the 20930 code that its October 31,
2018, EOB eventually denied in renege fashion. But again, so as to streamline this matter legally (not turn this
matter into a “right of payment’ dispute), SCV forgoes recovery of the amounts involved in the four Al line-
items that Defendants’ EOB denied.
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXissued information to SCV approving surgical codes. As mentioned above, this paperwork is
attached as Exhibit D.
13. As mentioned above, SCV’s billed charges for the subject medical services
rendered to D.B. totaled $258,200.00 (see Ex. E) or $246,328.00 when the $11,818.00 waiver
discussed in footnote 7 is taken into consideration, and a claim package was promptly submitted
to Cigna relating to same via certified mail (certificate number 7001 2510 0003 9686 0428).
The SCV cover letter to its claim submission packet is attached hereto as Exhibit G and makes
specific reference to SCV’s appropriate expectation that claim payment would unfold pursuant
to one of the germane re-pricing contracts (see Ex. C) that existed (not some unknown
Defendants’ re-pricing contract that Defendants would eventually unilaterally employ), which,
again, such re-pricing contracts (even the yet discovered mystery Defendants’ re-pricing
formula) do not “relate to” the Plan document (Exhibit A); i.e., again, resolution of Counts I-III
(which hinge on the appropriate re-pricing mechanism) will require little (if any) reference to
Exhibit A and certainly not a substantive reference to / “interpretation of’ Exhibit A, which
such substantive reference / “interpretation of” a plan document (rather than a cursory glance at
a plan document, as might be required here) in order to resolve a rate of payment dispute is what
would militate toward “relation to” defensive ERISA preemption.
14. At all material times, Cigna was in agreement with Preferred Medical Claim
Solutions (“PMCS”) (as Cigna’s affiliate and / or subcontractor and / or vendor and / or agent
and / or the like) and / or MultiPlan (as Cigna’s affiliate and / or subcontractor and / or vendor
and / or agent and / or the like) to secure discounted rates from providers (like SCV), which
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXwere secured here in relation to SCV.”
15, The PMCS allowed amount re-pricing contract (see Ex. C) was in full force
and effect and was a legally valid and binding contract that established / developed (a) an
allowed amount re-pricing rate of 80% of SCV’s billed charges less patient responsibilities
(e.g., co-pay, deductible, co-insurance) subject to the patient’s annual out-of-pocket maximum,
and (b) a 100% reimbursement rate for hard costs (e.g., prosthetics / implants). The MultiPlan
allowed amount re-pricing contract (see Ex. C) was in full force and effect and was a legally
valid and binding contract that established / developed the same type of re-pricing structure as
that noted above in relation to PMCS, but at 60% of SCV’s billed charges (rather than 80%)
and 120% reimbursement of hard costs (rather than 100%).
16. Notwithstanding the existing PMCS and MultiPlan contracts / agreements in
place (which, again, were arranged by Cigna with PMCS and MultiPlan as its vendors / agents),
by way of EOBs dated March 19, 2018, and October 31, 2018, on Cigna letterhead, Defendants
underpaid the subject claim, tendering $38,967.90 in total predicated on some mystery re-
pricing formula falling outside Exhibit A implemented by Cigna and / or whatever mystery re-
pricer Defendants enlisted. More specifically, Defendants failed to properly pay (proper
amount, that is) the codes billed by SCV in connection with the medical procedure.
17. This matter does not present a coverage dispute (i.e., “right of payment” dispute)
°Again, a copy of the pertinent pages of the PMCS and MultiPlan re-pricing contracts that were procured on
Cigna’s behalf (along with the PMCS and MultiPlan “client” lists listing Cigna) are attached hereto as Exhibit C.
Again, Exhibit C is incorporated fully herein by reference. Of note, in its claim submission cover letter (see Ex.
G), SCV made clear its expectation that the claim would be re-priced pursuant to these re-pricing contracts /
agreements that were brokered by Cigna with PMCS and MultiPlan being Cigna’s vendor, agent, or the like tasked
with achieving discounted rates from medical providers like SCV.
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXbecause Defendants properly conceded coverage via the $38,967.90 partial claim payment (and
pre-authorization paperwork, for that matter, see Ex. D) and did not list any medical judgment
telated basis (e.g., medical necessity or experimental / investigational) for partial payment
amongst the claim decision EOB codes (see Ex. F) / HCFA codes (see Ex. E) that SCV places
at issue here (see n. 7, supra). Rather, this is a damages dispute (i.¢., “rate of payment” dispute)
pertaining solely to the underpayment that was predicated on Defendants’ aberrant claim
decision-making seemingly predicated on the unsubstantiated mystery rate system employed (if
a system even exists) by Defendants. And, again, whatever mystery Defendants’ re-pricing
contract / formula / agreement / program that was employed by Defendants is outside of Exhibit
A. To be clear, and again, this dispute revolves around the re-pricing established by Defendants
separate and distinct from Exhibit A and SCV’s contention that the re-pricing contracts separate
and distinct from Exhibit A that should have been employed (see Ex. C). To be clear, and again,
the re-pricing dispute does not involve a substantive “interpretation of’ (or perhaps any
“interpretation of”) Exhibit A.
18. Following the adverse Defendants’ claim underpayment via EOBs dated March
19, 2018, and October 31, 2018, appeals and / or reconsideration processes were timely carried
out by SCV, culminating with SCV’s February 26, 2019, second level appeal letter and March
4, 2019, external review request.
19. As for Defendants, the pre-suit administrative appeals process culminated with
Cigna’s March 8, 2019, letter, which stated, in pertinent part, as follows: “There’s no need for
this appeal any longer. We’ve made the decision to approve coverage for the services you
teceived.” Again, this is not a coverage dispute, this is a damages (i.e., rate of payment) dispute.
10
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXTo be clear, SCV did not receive any additional payments from Defendants following the
October 31, 2018, EOB and associated $9,546.00 payment from Defendants to SCV;"° i.e., it
seems Defendants upheld their $38,967.90 payment decision, but we have no idea why or how.
20. Thereafter, undersigned counsel advised of his SCV representation and
tequested production of various germane documents, which Cigna purports to have provided
on Defendants’ behalves. See n. 4, supra.
21. Again, if one looks at the EOBs (which do not necessitate examination or
“interpretation of” Exhibit A), it is plain that coverage is not at issue here — Defendants properly
conceded coverage via initial partial payments. See Ex. F. And, again, as to the codes that SCV
places at issue in this lawsuit, one can also look to the pre-authorization paperwork (which does
not necessitate examination or “interpretation of’ Exhibit A) to see that coverage is not at issue
here. See Ex. D (as stated earlier, Exhibit D shows that the subject pre-authorization put
coverage issues to rest, leaving only pricing issues). Again, the sole issue here is one of payment
amount, so we turn now to germane insurance policy language in that vein just for a baseline
understanding (not at all for substantive reliance).
22. As to re-pricing, the insurance policy / Plan document (Ex. A) provides that
payment of benefits is based on a MRC, as follows, in pertinent part:
Cigna’s out-of-network coinsurance payments take into account what is
ordinarily paid for a service or supply in the area where it is delivered. This
maximum reimbursable charge (MRC) is used as the basis for determining the
plan’s share of most out-of-network payments. Here’s how this works:
« If an out-of-network provider charges less than the MRC for services delivered
to you, coinsurance will be based on that lower amount
10 The March 19, 2018, EOB was coupled with a $29,421.90 payment from Defendants to SCV.
11
Filing 131905985 VS 05-2021-CA-039677-XXXX-XX¢ If an out-of-network provider charges in excess of the MRC, the plan’s
reimbursement will be based on the MRC and you will owe your percentage of
coinsurance plus whatever balance is due the provider.
Ex. A at IV-16. The insurance policy / Plan document defines MRC as follows:
The lesser of these two charges: the provider’s normal charge for a similar
service or supply or a charge representing a percentage of what is ordinarily
paid for a service or supply in a geographic area. The healthcare professional
may bill the customer the difference between the healthcare professional’s
normal charge and the MRC as determined by the benefit plan, in addition to
applicable deductibles, copays and coinsurance.
Id. at 1V-4 (emphasis in original). The “two charges” are exactly what PMCS and MultiPlan
(Cigna’s repricing vendors) determine in establishing rate of payment. This is where the
fleeting examination of Exhibit A would end in this case, which such fleeting examination does
not rise to the level needed to establish “relation to” ERISA defensive preemption.
23. Again, where (as here) separate and distinct re-pricing contracts / agreements
have been established to determine “the provider’s normal charge for a similar service” or “a
charge representing a percentage of what is ordinarily paid for a service or supply in a
geographic area,” see Ex. C, such a contract / agreement controls. Defendants’ own conduct
evidences that much at least — Defendants implemented a mystery re-pricing contract /
agreement / formula / program separate and distinct from Exhibit A, leading to the amounts of
payment furnished under EOBs dated March 19, 2018, and October 31, 2018. So, Defendants
should not now (through their lawyers’ ex post facto arguments) be heard to say that “relation
to” defensive preemption applies to this dispute — at minimum, what is good for the goose is
good for the gander; i.e., at minimum, waiver and / or estoppel are at play.
24. Defendants’ implementation of their mystery re-pricing contract / agreement /
formula / program is untenable because SCV did not agree to same and, more importantly, the
12
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXparties had previously agreed to rate of payment contracts (see Ex. C).
25. Once more, to date, it is unclear how Defendants ended up re-pricing the
subject claim and / or why Defendants deviated from (or reneged on) the re-pricing contracts
that had been established between the parties (see Ex. C). But what is clear is that this dispute
tevolves around re-pricing contracts separate and distinct from the Plan document (Ex. A) and
is accordingly not defensively preempted.
26. Defendants wronged SCV in many ways, most notably by way of the
significant underpayment. Defendants should have employed the PMCS or MultiPlan re-
pricing contracts (Ex. C) already in place (i.e., already agreed to between the parties) to assess
a proper re-priced amount; but, instead, Defendants implemented a mystery re-pricing system
(not agreed to by SCV) separate and distinct from Exhibit A to arrive at the rate of payment at
issue.
27. Under the PMCS re-pricing analysis (which, again, was a re-pricing contract /
agreement established by Cigna that SCV actually agreed to, along with the MultiPlan re-
pricing contract / agreement established by Cigna that SCV actually agreed to, and unlike the
Defendants’ mystery re-pricing contract / agreement / formula / program that Defendants
unilaterally employed here without SCV’s agreement), for example,'! Defendants should have
used an 80% rate to calculate the allowed amount equaling $211,156.00 (which such amount
is 80% of all non-implant HCFA line-items and 100% of all implant HCFA line-items).'? This
is the amount that the assumed patient responsibilities (capped at an annual out-of-pocket
1 “For example” because the MultiPlan re-pricing contract, see Ex. C, is also available for use by the trier of fact.
!2 This PMCS-oriented re-price uses $246,382.00 as the billed amount; i.e., takes into consideration the line-items
that SCV foregoes recovery on. See n. 7, supra.
13
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXmaximum) should have been deducted from. The $211,156.00 less Defendants’ prior payment
(which such prior payment presumably already took patient responsibilities subject to the
annual out-of-pocket maximum into consideration) leaves an outstanding balance of
$172,188.10 due and owing to SCV. This amount is exclusive of attorneys’ fees, costs, interest,
and / or extra-contractual exposure.
28. SCV has suffered significant financial harm no matter how one slices this
situation. The financial harm by way of owed medical services monies is in excess of
$75,000.00, not including interest of attorneys’ fees, costs, or interest, if, for examples, the
negotiated, agreed to 80% / 100% rate prescribed by Cigna’s third-party re-pricing vendor
(PMCS) is honored / enforced as it should be, or even if rates prescribed by publicly available
databases assessing the charges of providers of like kind within like geographies, like Agency
for Health Care Administration (“AHCA”),'* were utilized in the re-pricing assessment.
29. SCV exhausted the pre-suit appeal process in an effort to accomplish
Defendants’ doing the right thing (i.¢., properly compensating SCV) sans litigation, to no avail.
Hence, this lawsuit as SCV’s regrettable last resort.
COUNT I - BREACH OF CONTRACT (CLAIM UNDERPAYMENT)
SCV re-alleges Paragraphs 1 through 29 as if fully set forth herein, and further alleges
as follows.
30. At all material times to this action and in exchange for a valuable premium,
Defendants provided health insurance to D.B. under the Plan document (Exhibit A).
13 See, eg, http:/Avww. floridahealthfinder. gov/LandingPages/HospitalASC.aspx and
http://www. floridahealth finder.gov/CompareCare/SelectChoice.aspx.
14
Filing 131905985 VS 05-2021-CA-039677-XXXX-XX31. The subject medical services were covered under the Plan document, as
evidenced by, for examples, (a) Defendants’ partial payment relating to same, (b) the Cigna-
issued EOBs (Ex. F), (c) pre-authorization paperwork (Ex. D) approving the subject HCFA
codes (Ex. E), and (d) et cetera. A fuller discussion as to why coverage is not at issue in this
pure pricing dispute can be found in the above common allegations, namely Paragraphs 9-10.
32. Defendants erred in deciding to not fully compensate SCV by only tendering
a $38,967.90 underpayment in relation to $246,382.00 in billed charges (see n. 12, supra)
predicated on Defendants’ mystery re-pricing contract / agreement / formula / program
separate and distinct from Exhibit A. As to all codes set forth on the HCFA (Ex. E), Defendants
should have honored the re-pricing contracts (PMCS and / or MultiPlan) included in Exhibit
C that the parties had actually already agreed to. Defendants’ payment amount comes nowhere
close to the re-pricing formulas prescribed by PMCS (80% HCFA non-implant codes / 100%
HCFA implant codes), for example. See § 27, supra. Defendants’ payment amount is
accordingly in breach of the subject re-pricing contracts (Ex. C).!*
33. Defendants’ $38,967.90 underpayment does not constitute a usual, customary,
teasonable re-priced / allowed amount no matter how one views the situation. First, for
example, third-party repricing vendors who Cigna contracts with (e.g., PMCS, MultiPlan) have
established SCV’s UCR (or MRC) based re-priced / allowed amount at 80% of billed charges
(at least pursuant to PMCS in relation to non-implant HCFA line-items). Second, as another
example, unbiased public databases (e.g., AHCA) assessing the rates of providers of like kind
4 And, again, at minimum, Defendants’ payment amount also does not come anywhere close to typical rates
within the subject geography. Again, that kind of information can be easily found in the public domain through
very reputable sources, see n. 13, supra.
15
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXwithin like Florida geographies make clear that Defendants’ unsubstantiated rate of payment
does not find support amidst UCR rates relating to providers of like kind within like Florida
geographies.
34, Defendants, among other things, had a duty to properly investigate the subject
medical services, adjust / investigate the subject SCV claim relating to such services, and fully
compensate SCV in relation to same. Defendants failed SCV in these regards (most notably
with respect to their failure to pay the monies due and owing under the subject re-pricing
contracts), which breached the subject re-pricing contracts / agreements and / or violated
Florida law.
35, As a direct, foreseeable, and proximate result of Defendants’ breach of their
obligations under the re-pricing contracts, SCV has suffered and continues to suffer damages.
36. SCV has no other adequate remedy other than this lawsuit to address the
injuries it has suffered as a result of Defendants’ underpayment of the monies owed to it in
telation to the subject D.B. medical services.
37. As a further result of Defendants’ refusal to fully compensate SCV, SCV has
been forced to retain legal counsel to represent it in this matter and is accordingly entitled to
recover its reasonable attorneys’ fees and costs pursuant to Section 627.428 of the Florida
Statutes or as otherwise awardable.
WHEREFORE, Plaintiff, Surgery Center of Viera, LLC, requests the entry of judgment
against Defendants, Cigna Health and Life Insurance Company, Harris Corporation Group
Insurance Plan, and Harris Corporation, for liability and for damages including, but not limited
to, (a) past-due contractual monies owed in relation to the subject medical services and all
16
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXassociated awardable accrued interest, (b) attorneys’ fees pursuant to Section 627.428 of the
Florida Statutes or as otherwise awardable, (c) costs incurred bringing this action, and (d) for
such other relief as this Court deems equitable, just and proper.
COUNT II —- UNJUST ENRICHMENT
SCV re-alleges Paragraphs 1 through 29 as if fully set forth herein, and further alleges
as follows.
38. SCV conferred a direct benefit on Defendants by providing Defendants’
insured / member (D.B.) with medical services to which the insured was entitled under the
insurance policy (covered) as evidenced by Defendants’ partial payment. Examples of
“conferral of benefit” would include the following, for examples, which are posed as questions:
(a) What about Defendants receiving the benefit when their policyholder / employee received
care and treatment offering Defendants’ insurance policy as their primary method of payment?
(b) What about the good health of D.B. conferred on Defendants? Was it not of benefit to
Defendants that SCV minimized (if not entirely eliminated, actually) D.B.’s future medical
expense (and insurance claims to Defendants) relating to the subject conditions such as
prolonged alternative treatments or a return for more (and perhaps more complex) surgery due
to complications arising out of some other inferior treatment regimen?
39. Defendants voluntarily accepted and received the benefit conferred by SCV,
with the knowledge that SCV expected to be paid the reasonable value of its services; i.e.,
SCV’s usual, customary, reasonable charges as prescribed by reasonable, negotiated re-pricing
vendors (e.g., PMCS, MultiPlan) or, for that matter, as prescribed by Florida’s publicly
available AHCA database assessing rates of various medical providers of like kind within like
17
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXgeography. Again, as to Defendants’ knowledge, there are several things supportive of same
in the above common allegations; e.g., the pre-authorization process, SCV’s claim submission
package cover letter and HCFA, the parties’ past dealings with each other, and et cetera.
40. Defendants voluntarily accepted and received the benefit conferred by SCV,
with the knowledge (through course of past dealings with SCV that included claim submission
cover letters such as that attached as Exhibit G indicating re-pricing contract expectations, or
otherwise) that SCV expected to be paid the reasonable value of its services; i.¢., SCV’s UCR
charges as prescribed by reasonable re-pricing vendors (e.g., PMCS, MultiPlan) or, for that
matter, as prescribed in the Florida’s publicly available AHCA database assessing rates of
various medical providers of like kind within like geography.
41. Defendants have not paid the value of the benefit conferred by SCV in that
Defendants have significantly underpaid SCV’s claim for monies owed in relation to the
medical services provided to D.B.
42. Defendants’ underpayment results in a windfall for Defendants in that (a)
Defendants collect premiums in return for agreeing to properly compensate providers, like
SCV, who render covered medical services, and / or (b) Defendants enjoy an unearned profit
in relation to the insurance benefits themselves, in relation to interest that has accrued on the
wrongly withheld benefits, in relation to investment returns enjoyed through the monies
wrongly withheld from SCV, in relation to level-funded plan profits enjoyed through the
wrongly withheld monies, and / or et cetera.
43. It is unjust under the circumstances for Defendants to underpay SCV’s claim.
44. SCV has no other adequate remedy other than this lawsuit to address the
18
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXinjuries it has suffered as a result of Defendants’ underpayment of the monies owed to it in
relation to the subject medical services.
45. As a further result of Defendants’ refusal to fully compensate SCV, SCV has
been forced to retain legal counsel to represent it in this matter and is accordingly entitled to
tecover its reasonable attorneys’ fees and costs pursuant to Section 627.428 of the Florida
Statutes or as otherwise awardable.
WHEREFORE, Plaintiff, Surgery Center of Viera, LLC, requests the entry of judgment
against Defendants, Cigna Health and Life Insurance Company, Harris Corporation Group
Insurance Plan, and Harris Corporation, for liability and for damages including, but not limited
to, (a) past-due monies owed for the subject medical services and all associated awardable
accrued interest, (b) attorneys’ fees pursuant to Section 627.428 of the Florida Statutes or as
otherwise awardable, (c) costs incurred bringing this action, and (d) for such other relief as this
Court deems equitable, just and proper.
COUNT II —- QUANTUM MERUIT
SCV re-alleges Paragraphs 1 through 29 as if fully set forth herein, and further alleges
as follows.
46. SCV conferred a direct benefit on Defendants by providing Defendants’ insured
/ member (D.B.) with medical services to which the insured was entitled under the insurance
policy (covered) as evidenced by Defendants’ partial payment. Examples of “conferral of
benefit” (in the form of questions) are discussed in Paragraph 38, supra, and incorporated into
this count by reference.
19
Filing 131905985 VS 05-2021-CA-039677-XXXX-XX47. SCV billed Defendants its UCR charges for the services as prescribed by
reasonable re-pricing vendors (e.g., PMCS, MultiPlan) or, for that matter, as prescribed by
Florida’s publicly available AHCA database assessing rates of various medical providers of
like kind within like geography. The billed charges represent the fair market value of the
services rendered.
48. Defendants received the bill from SCV but underpaid SCV for the services.
49. Animplied contract was doubtless established through Defendants’ knowledge
that services were being rendered and both sides intended for compensation to be paid, with
the parties possessing the compensation intention through the course of their past dealings
(such as through claim submission letters like Exhibit G routinely furnished to Cigna indicating
SCV’s expectation to be paid pursuant to the subject re-pricing contracts) or otherwise.
50. In order for the implied contract to have been formed, Defendants did not have
to be the recipient of the services or request the services.
51. SCV is entitled to reasonable compensation for the services (i.e., quantum
meruit), which is by no means accomplished by Defendants’ unsubstantiated rate of payment
but is reflected in reasonable sources such as third-party re-pricing vendors’ (e.g., PMCS,
MultiPlan) or Florida’s publicly available AHCA databases of assessments of SCV’s rates.
And determination of the proper amount of compensation is a question of fact reserved for a
jury.
52. The circumstances are such that it would be inequitable for Defendants to retain
the benefit of the subject medical services without paying SCV the proper value for same.
20
Filing 131905985 VS 05-2021-CA-039677-XXXX-XX53. SCV has no other adequate remedy other than this lawsuit to address the injuries
it has suffered as a result of Defendants’ underpayment of the monies owed to it in relation to
the subject medical services.
54. Asa further result of Defendants’ refusal to fully compensate SCV, SCV has
been forced to retain legal counsel to represent it in this matter and is accordingly entitled to
recover its reasonable attorneys’ fees and costs pursuant to Section 627.428 of the Florida
Statutes or as otherwise awardable.
WHEREFORE, Plaintiff, Surgery Center of Viera, LLC, requests the entry of judgment
against Defendants, Cigna Health and Life Insurance Company, Harris Corporation Group
Insurance Plan, and Harris Corporation, for liability and for damages including, but not limited
to, (a) past-due monies owed for the subject medical services and all associated awardable
accrued interest, (b) attorneys’ fees pursuant to Section 627.428 of the Florida Statutes or as
otherwise awardable, (c) costs incurred bringing this action, and (d) for such other relief as this
Court deems equitable, just and proper.
JURY DEMAND
55. Plaintiff, Surgery Center of Viera, LLC, demands a trial by jury on all issues so
triable as a matter of right.
Dated: July 21, 2021
21
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXRespectfully Submitted,
CALLAGY LAW, P.C.
1900 N.W. Corporate Blvd., Ste 310W
Boca Raton, Florida 33431
(561) 405-7966 (0); (201) 549-8753 (f)
/s/ Jeffrey L. Greyber
Jeffrey L. Greyber, Esq.
Fla. Bar No. 41103
jgreyber@callagylaw.com
hcasebolt@callagylaw.com
Attorney for Plaintiff
22
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXExhibit A
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXHarris Corporation
OPEN ACCESS PLUS MEDICAL
BENEFITS
OAP 850/1700
Active Employees
EFFECTIVE DATE: January 1, 2017
ASO28 (OAP3)
3337001
This document printed in April, 2017 takes the place of any documents previously issued to you which
described your benefits.
Printed in U.S.A.
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXFiling 131905985 VS 05-2021-CA-039677-XXXX-XXTable of Contents
Important Information.
Special Plan Provisions.
seve
Important Notices ...
How To File Your Claim .....sssssscsrsenssesssessscssnacssesnssssenaseranesavesenesrenees
Eligibility - Effective Date........ soesnees coveconssennenesensossesssvesavcesnecossceausenuecassconsconscosssonesennonsseesvedtiiesD)
Employee Insurance . 9
Waiting Period......
Dependent Insurance...
Important Information About Your Medical Plan...
Open Access Plus Medical Benefits ........sssssssssssssessessesosensssesnessnpssesenseeasnessseannesterssneensnannsnrenrsord
The Schedule ..... wool
Certification Requirements - Out-of-Network 24
Prior Authorization/Pre-Authorized ....
Covered Expenses ....
.24
wee DS
Exclusions, Expenses Not Covered and General Limitations ........:csseeneceeeeeeneenenn dd
Coordination of Benefits... ssesensavacoenazerennequsdannnneareperesennnennere
Expenses For Which A Third Party May Be Responsible vessoseone ssrneeansesnseeneeeane DD
Payment of Benefits ......csesesssesesssessesserevn
Termination of Insurance...
Employees......
Dependents
Rescissions
Federal Requirements .........s00
Notice of Provider Directory/Networks....
Qualified Medical Child Support Order (QMCSO) ..
Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA)
Effect of Section 125 Tax Regulations on This Plan......
Eligibility for Coverage for Adopted Children
Coverage for Maternity Hospital Stay......
Women’s Health and Cancer Rights Act (WHCRA)
Group Plan Coverage Instead of Medicai
Requirements of Medical Leave Act of 1993 (as amended) (FMLA)
Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)
Claim Determination Procedures under ERISA......
Medical - When You Have a Complaint or an Appeal
COBRA Continuation Rights Under Federal Law.....
ERISA Required Information.......
Definitions .......sccseseersesees
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXImportant Information
THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR
ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY HARRIS CORPORATION WHICH IS
RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY
(CIGNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT
INSURE THE BENEFITS DESCRIBED.
THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE
THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO
INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CIGNA,"
"INSURANCE COMPANY," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR
"EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND
"INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE."
HC-NoTt
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXExplanation of Terms
You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms
are defined in the Definitions section of your certificate,
The Schedule
The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description
of each benefit, refer to the appropriate section listed in the Table of Contents.
Filing 131905985 VS 05-2021-CA-039677-XXXX-XXSpecial Plan Provisions
When you select a Participating Provider, this Plan pays a
greater share of the costs than if you select a non-Participating
Provider, Participating Providers include Physicians, Hospitals
and Other Health Care Professionals and Other Health Care
Facilities. Consult your Physician Guide for a list of
Participating Providers in your area. Participating Providers
are committed to providing you and your Dependents
appropriate care while lowering medical costs.
Services Available in Conjunction With Your Medical
Plan
The following pages describe helpful services available in
conjunction with your medical plan. You can access these
services by calling the toll-free number shown on the back of
your ID card.
HC-SPP 04-16
vl
Case Management
Case Management is a service provided through a Review
Organization, which assists individuals with treatment needs
that extend beyond the acute care setting. The goal of Case
Management is to ensure that patients receive appropriate care
in the most effective setting possible whether at home, as an
outpatient, or an inpatient in a Hospital or specialized facility.
Should the need for Case Management arise, a Case
Management professional will work closely with the patient,
his or her family and the attending Physician to determine
appropriate treatment options which will best meet the
patient's needs and keep costs manageable. The Case Manager
will help coordinate the treatment program and arrange for
necessary resources, Case Managers are also available to
answer questions and provide ongoing support for the family
in times of medical crisis.
Case Managers are Registered Nurses (RNs) and other
credentialed health care professionals, each trained in a
clinical specialty area such as trauma, high risk pregnancy and
neonates, oncology, mental health, rehabilitation or general
medicine and surgery. A Case Manager trained in the
appropriate clinical specialty area will be assigned to you or
your dependent. In addition, Case Managers are supported by
a panel of Physician advisors who offer guidance on up-to-
date treatment programs and medical technology. While the
Case Manager recommends alternate treatment programs and
helps coordinate needed resources, the patient's attending
Physician remains responsible for the actual medical care.
You, your dependent or an attending Physician can request
Case Management services by calling the toll-free number
shown on your ID card during normal business hours,
Monday through Friday. In addition, your employer, a claim
office or a utilization review program (see the PAC/CSR.
section of your certificate) may refer an individual for Case
Management.
The Review Organization assesses each case to determine
whether Case Management is appropriate.
You or your Dependent is contacted by an assigned Case
Manager who explains in detail how the program works.
Participation in the program is voluntary - no penalty or
benefit reduction is imposed if you do not wish to
participate in Case Management.
Following an initial assessment, the Case Manager works
with you, your family and Physician to determine the needs
of the patient and to identify what alternate treatment
programs are available (for example, in-home medical care
in lieu of an extended Hospital convalescence). You are not
penalized if the alternate treatment program is not followed.
.
.
The Case Manager arranges for alternate treatment services
and supplies, as needed (for example, nursing services or a
Hospital bed and other Durable Medical Equipment for the
home).
The Case Manager also acts as a liaison between the insurer,
the patient, his or her family and Physician as needed (for
example, by helping you to understand a complex medical
diagnosis or treatment plan).
Once the alternate treatment program is in place, the Case
Manager continues to manage the case to ensure the
treatment program remains appropriate to the patient's
needs.
While participation in Case Management is strictly voluntary,
Case Management professionals can offer quality, cost-
effective treatment alternatives, as well as provide assistance
in obtaining needed medical resources and ongoing family
support in a time of need.
.
.
HC-SPP2 08-40
vi
Additional Programs
We may, from time to time, offer or arrange for various
entities to offer discounts, benefits, or other consideration to
our members for the purpose of promoting the general health
and well being of our members. We may also arrange for the
reimbursement of all or a portion of the cost of services
Filing 131905985 VS
myCigna.com
05-2021-CA-039677-XXXX-XXwie ne
Né Cigna.
provided by other parties to the Policyholder. Contact us for
details regarding any such arrangements.
HC-SPPS onto
Care Management and Care Coordination Services
Your plan may enter into specific collaborative arrangements
with health care professionals committed to improving quality
care, patient satisfaction and affordability. Through these
collaborative arrangements, health care professionals commit
to proactively providing participants with certain care
management and care coordination services to facilitate
achievement of these goals. Reimbursement is provided at
100% for these services when rendered by designated health
care professionals in these collaborative arrangements.
ue-spP27 06-13
vi
Important Notices
Direct Access to Obstetricians and Gynecologists
You do not need prior authorization from the plan or from any
other person (including a primary care provider) in order to
obtain access to obstetrical or gynecological care from a health
care professional in our network who specializes in obstetrics
or gynecology. The health care professional, however, may be
required to comply with certain procedures, including
obtaining prior authorization for certain services, following a
pre-approved treatment plan, or procedures for making
referrals. For a list of participating health care professionals
who specialize in obstetrics or gynecology, visit
www. mycigna.com or contact customer service at the phone
number listed on the back of your ID card.
Selection of a Primary Care Provider
This plan gener
Preview
Filing # 131905985 E-Filed 08/03/2021 10:01:49 AM IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA CIVIL DIVISION CASE NO.: SURGERY CENTER OF VIERA, LLC, Plaintiff, v. CIGNA HEALTH AND LIFE INSURANCE COMPANY, HARRIS CORPORATION GROUP INSURANCE PLAN, and HARRIS CORPORATION, Defendants. COMPLAINT Plaintiff, Surgery Center of Viera, LLC (“SCV”), as medical provider, authorized tepresentative, and assignee of patient / insured, D.B, sues Defendants, Cigna Health and Life Insurance Company (“Cigna”), Harris Corporation Group Insurance Plan (the “Plan”), and Harris Corporation (“Harris”),':?*> as follows: 1 Upon information and belief, in the summer of 2019, Harris Corporation, a Delaware corporation, became known as (or merged with) L3 Harris Technologies, Inc., a Delaware corporation. But, as discussed below, the subject medical procedure occurred on January 23, 2018, so this Complaint involves the parties and Plan document in existence at that time. ? The Plan document is attached hereto as Exhibit A and fully incorporated herein by reference, which such Plan document was tendered by Cigna to SCV under letters dated January 27, 2020, and February 5, 2020. Upon information and belief, the Plan is self-funded; but, if discovery reveals the Plan was / is fully-insured (as opposed. to self-funded), the Harris Defendants would not need to be part of the benefits amount dispute (Counts I-IID; i.e., could be dismissed from this action without prejudice. 3 It would appear from Exhibit A that the name of the Plan is Harris Medical Plan, see, e.g., Ex. A at IV-2 (... this description of the Harris Medical Plan...”), but we have been advised before by these same Defendants that Harris Corporation Group Insurance Plan is the proper name of the Plan. Filing 131905985 VS 05-2021-CA-039677-XXXX-XXNATURE OF THE ACTION, PARTIES, JURISDICTION, AND VENUE 1. This action arises (Counts I-III), under state law for Defendants’ wrongful, unsubstantiated underpayment of monies owed to SCV for medical services SCV provided to the patient / insured, D.B., on January 23, 2018, which such causes of action have absolutely nothing to do with “right of payment” / coverage (i.e., have everything to do with “rate of payment” / benefits underpayment) and which such causes of action have to do with third- party re-pricing contracts separate and distinct from the insurance policy / Plan document.* 2. At all material times, SCV was a medical provider and a Florida limited liability company with its citizenship (i.e., principal place of business / “nerve center”) in Viera, Florida, Brevard County. SCV is sui juris in all respects. SCV’s members are as follows: (a) Dr. Ara Deukmedjian, domiciled in Brevard County, Florida, (b) Sun Deukmedjian, domiciled in Brevard County, Florida, and (c) Dr. Bharat Patel, domiciled in Brevard County, Florida. At all material times, SCV was the authorized representative of D.B. with an assignment of benefits as well,> having provided subject medical services to D.B. for which a proper amount of compensation (Counts I-III) was / is due and owing. And, again, Defendants honored such authorized representative and assignee capacities by, for examples, carrying out pre-suit appeals with SCV and tendering partial claim payments directly to SCV. 3. Atall material times, Cigna was an insurance company incorporated in the State of Connecticut and engaged in the business of selling and / or administering health insurance 4 If discovery reveals that Defendants’ purported administrative record production (under Cigna letters dated January 27, 2020, and February 5, 2020) was / is not complete, SCV reserves the right to amend this Complaint. > All germane authorization and / or assignment paperwork in SCV’s possession is attached hereto as Exhibit B (in redacted form) and incorporated fully herein by reference. Filing 131905985 VS 05-2021-CA-039677-XXXX-XXand / or deciding health insurance claims (i.e., claim administering). Upon information and belief, Cigna’s principal place of business is also in the State of Connecticut. 4. At all material times, Harris Corporation (and L3 Harris Technologies, Inc., for that matter at non-material times, see n. 1, supra), was a technology company incorporated in the State of Delaware and engaged (in pertinent part here) in the administration and / or sponsorship of the Plan. Upon information and belief, Harris Corporation’s principal place of business is in the State of Florida. Upon information and belief, the Plan is not separate and distinct from Harris (at least not with respect to jurisdictional citizenship); i.e., would share the same state of incorporation and principal place of business information. 5. This Court has jurisdiction over this matter pursuant to Section 26.012 of the Florida statutes, as the amount in controversy exceeds the sum of $30,000.00, exclusive of attorneys’ fees, interest, and costs. 6. Venue is proper in this Court pursuant to Section 47.011 of the Florida Statutes because, for examples, (a) a substantial part of the events or omissions giving rise to the subject action occurred in this jurisdiction, namely the subject medical procedure and Defendants’ underpayment of the subject insurance claim both at the initial claim and subsequent pre-suit appeal stages (Counts I-III), and (b) the Defendants conduct business in this jurisdiction. 7. All conditions precedent to the institution of this action (e.g., administrative pre- suit appeals) have occurred, been performed, been waived, or were futile. COMMON ALLEGATIONS 8. The patient’s Member I.D. number was / is 000211169 01, the assigned claim Filing 131905985 VS 05-2021-CA-039677-XXXX-XXteference number was / is 9431803493452, the patient account number was / is 000200012804, and the authorization code (discussed again below) was / is B44NSKK1. Again, a copy of the insuring agreement (which is separate and distinct from the re-pricing contracts / agreements at issue in this lawsuit, see Exhibit C incorporated fully herein by reference, and / or whatever mystery re-pricing contract / agreement / formula / program that Defendants implemented in arriving at the rate of payment furnished here) is attached as Exhibit A and incorporated fully herein by reference. 9. At all material times, D.B. was covered (i.e., coverage is not an issue here) by the Plan as evidenced by several things, with examples now discussed (and more discussed below). a. If D.B. was not an eligible / covered insured, the subject claim would not have been paid by Defendants in any amount, and this eligibility and claim payment correlation reality is stated in the pre-authorization paperwork discussed below and attached as Exhibit D. Exhibit D is incorporated fully herein by reference. b. Ifthe subject surgery (which such surgery was broken down by codes found in the HCFA found in SCV’s initial claim submission packet) had not been covered,° the subject claim would not have been paid by Defendants in any amount. Regarding coverage of the subject HCFA codes, Defendants’ EOBs furnished by Cigna (further discussed below) are attached as Exhibit F and evidence Defendants’ coverage decision. Exhibit F (made up of EOBs dated © The HFCA form that was part of SCV’s thirteen-page claim submission package to Defendants, which such claim submission package is noted below, is attached as Exhibit E. This HCFA exhibit is incorporated fully herein by reference. Filing 131905985 VS 05-2021-CA-039677-XXXX-XXMarch 19, 2018, and October 31, 2018) is incorporated fully herein by reference. And as one can plainly see from the Cigna-issued EOBs, Defendants unilaterally re-priced the subject claim (somehow) and did not deny any aspects of the claim in dispute here on coverage grounds (e.g., medical necessity, experimental / investigational).’ To this day, we really have no idea how Defendants came up with payments totaling $38,967.90 (on a billed amount of $258,200.00, see Ex. E, or $246,328.00 when the $11,818.00 waiver discussed in footnote 7 is taken into consideration) because at every turn (SCV’s requests and undersigned counsel’s requests), Defendants have secreted how they came up with $38,967.90; i.e., have never substantiated their determination that $38,967.90 was a “usual, customary, reasonable” (“UCR”) amount (or the “maximum reimbursable charge,” “MRC”) of payment for the subject procedure. “Unilaterally” because applicable re-pricing contracts (that SCV had actually agreed to, unlike the unagreed to mystery Defendants’ re-pricing contract / agreement / formula / program) were already in place (see Ex. C). Again, Plaintiff presently does not possess the paperwork associated with the mystery Defendants’ re-pricing formula because Defendants have wrongly secreted this paperwork (the very paperwork that would evidence how on earth Defendants came up with their unreasonably low rate of payment) from SCV 7 “In dispute here” because SCV hereby forgoes any effort to obtain payment for the four Al codes identified on the October 31, 2018, EOB (see Ex. F) totaling $11,818.00. This waiver is done in the spirit of compromise where none should be required (because it was improper for Defendants to deny the four Al line-items) in order to legally streamline this action (not turn this matter into a “right of payment” dispute). Filing 131905985 VS 05-2021-CA-039677-XXXX-XXin their perpetual refusal to substantiate the unjustifiably low rate of payment force-fed to SCV here. But, as with the re-pricing contracts (Ex. C) that SCV maintains should apply here in determining the proper rate of payment, the mystery Defendants’ re-pricing contract / agreement / formula / program unilaterally implemented by Defendants in arriving at the disputed claim payment amount is also separate and distinct from the insurance policy / Plan document (Ex. A). Meaning, there is absolutely no “relation to” defensive ERISA preemption at play with a pricing dispute of this nature predicated on re-pricing contracts standing alone from Exhibit A. In sum, as evidenced by the variety of things noted in this averment, this action has nothing to do with coverage (i.e., “right of payment”), it has everything to do with the amount Defendants paid out (i.e., “rate of payment”) on covered HCFA codes based on a mystery Defendants’ re-pricing contract / formula / program separate and distinct from the Plan insurance document (Exhibit A). In other words, the mystery Defendants’ re-pricing contract / formula / program that Defendants used in re-pricing the subject claim and the re-pricing contracts / agreements (Ex. C) that SCV contends should have been used do not “relate to” the Plan document (Ex. A); i.e., resolution of Counts I-III will not relate to (at least not beyond a fleeting reference to, at most) the Plan document (Ex. A). Once more, “relation to” defensive ERISA preemption simply does not apply here in relation to Counts I-III. And as many Courts (several in this jurisdiction, to boot) have found, complete preemption most definitely does not apply to cases of this ilk. 10. The fact that this dispute has nothing to do with coverage (i.e., has everything Filing 131905985 VS 05-2021-CA-039677-XXXX-XXto do with pricing / rate of payment) is further evidenced by Defendants’ pre-surgery authorization paperwork (see Ex. D). The pre-surgery authorization paperwork (Ex. D) and process is designed to put coverage (but not the eventual amount of claim payment) to rest, which, as discussed above (and as evidenced by Ex. D) is what happened — Defendants deemed the subject procedure medically necessary (which such medical necessity would relate to coverage), other than the four HCFA line-items that SCV is not pursuing here. See n. 7, supra. Exhibit D is incorporated fully herein by reference.® 11. At all material times leading up to the subject medical services received from SCV, D.B. suffered from chronic lumbar pain with radiculopathy. D.B. tried alternative, conservative management treatments, which failed and surgical treatment was deemed medically necessary by both SCV (as evidenced by, for examples, the “operative note,” “history and physical,” and “letter of medical necessity for surgery” found in SCV’s claim submission package but not placed into the public domain at this juncture by way of Complaint exhibit due to SCV’s concern with preserving D.B.’s privacy rights and not turning an initial pleading into a complete evidence dump) and Defendants (as evidenced by, for example, the pre- authorization paperwork attached as Exhibit D, which such pre-authorization paperwork was also included in SCV’s claim submission package). So, on January 23, 2018, SCV operated on D.B. to remedy the medical conditions. 12. By facsimile dated January 22, 2018, and prior to the subject procedure, Cigna 8 For what it is worth, to the point made in footnote 7 above about Defendants’ eventual denial of four HCFA line-items being wrong, as one can see from Exhibit D, Cigna had approved the 20930 code that its October 31, 2018, EOB eventually denied in renege fashion. But again, so as to streamline this matter legally (not turn this matter into a “right of payment’ dispute), SCV forgoes recovery of the amounts involved in the four Al line- items that Defendants’ EOB denied. Filing 131905985 VS 05-2021-CA-039677-XXXX-XXissued information to SCV approving surgical codes. As mentioned above, this paperwork is attached as Exhibit D. 13. As mentioned above, SCV’s billed charges for the subject medical services rendered to D.B. totaled $258,200.00 (see Ex. E) or $246,328.00 when the $11,818.00 waiver discussed in footnote 7 is taken into consideration, and a claim package was promptly submitted to Cigna relating to same via certified mail (certificate number 7001 2510 0003 9686 0428). The SCV cover letter to its claim submission packet is attached hereto as Exhibit G and makes specific reference to SCV’s appropriate expectation that claim payment would unfold pursuant to one of the germane re-pricing contracts (see Ex. C) that existed (not some unknown Defendants’ re-pricing contract that Defendants would eventually unilaterally employ), which, again, such re-pricing contracts (even the yet discovered mystery Defendants’ re-pricing formula) do not “relate to” the Plan document (Exhibit A); i.e., again, resolution of Counts I-III (which hinge on the appropriate re-pricing mechanism) will require little (if any) reference to Exhibit A and certainly not a substantive reference to / “interpretation of’ Exhibit A, which such substantive reference / “interpretation of” a plan document (rather than a cursory glance at a plan document, as might be required here) in order to resolve a rate of payment dispute is what would militate toward “relation to” defensive ERISA preemption. 14. At all material times, Cigna was in agreement with Preferred Medical Claim Solutions (“PMCS”) (as Cigna’s affiliate and / or subcontractor and / or vendor and / or agent and / or the like) and / or MultiPlan (as Cigna’s affiliate and / or subcontractor and / or vendor and / or agent and / or the like) to secure discounted rates from providers (like SCV), which Filing 131905985 VS 05-2021-CA-039677-XXXX-XXwere secured here in relation to SCV.” 15, The PMCS allowed amount re-pricing contract (see Ex. C) was in full force and effect and was a legally valid and binding contract that established / developed (a) an allowed amount re-pricing rate of 80% of SCV’s billed charges less patient responsibilities (e.g., co-pay, deductible, co-insurance) subject to the patient’s annual out-of-pocket maximum, and (b) a 100% reimbursement rate for hard costs (e.g., prosthetics / implants). The MultiPlan allowed amount re-pricing contract (see Ex. C) was in full force and effect and was a legally valid and binding contract that established / developed the same type of re-pricing structure as that noted above in relation to PMCS, but at 60% of SCV’s billed charges (rather than 80%) and 120% reimbursement of hard costs (rather than 100%). 16. Notwithstanding the existing PMCS and MultiPlan contracts / agreements in place (which, again, were arranged by Cigna with PMCS and MultiPlan as its vendors / agents), by way of EOBs dated March 19, 2018, and October 31, 2018, on Cigna letterhead, Defendants underpaid the subject claim, tendering $38,967.90 in total predicated on some mystery re- pricing formula falling outside Exhibit A implemented by Cigna and / or whatever mystery re- pricer Defendants enlisted. More specifically, Defendants failed to properly pay (proper amount, that is) the codes billed by SCV in connection with the medical procedure. 17. This matter does not present a coverage dispute (i.e., “right of payment” dispute) °Again, a copy of the pertinent pages of the PMCS and MultiPlan re-pricing contracts that were procured on Cigna’s behalf (along with the PMCS and MultiPlan “client” lists listing Cigna) are attached hereto as Exhibit C. Again, Exhibit C is incorporated fully herein by reference. Of note, in its claim submission cover letter (see Ex. G), SCV made clear its expectation that the claim would be re-priced pursuant to these re-pricing contracts / agreements that were brokered by Cigna with PMCS and MultiPlan being Cigna’s vendor, agent, or the like tasked with achieving discounted rates from medical providers like SCV. Filing 131905985 VS 05-2021-CA-039677-XXXX-XXbecause Defendants properly conceded coverage via the $38,967.90 partial claim payment (and pre-authorization paperwork, for that matter, see Ex. D) and did not list any medical judgment telated basis (e.g., medical necessity or experimental / investigational) for partial payment amongst the claim decision EOB codes (see Ex. F) / HCFA codes (see Ex. E) that SCV places at issue here (see n. 7, supra). Rather, this is a damages dispute (i.¢., “rate of payment” dispute) pertaining solely to the underpayment that was predicated on Defendants’ aberrant claim decision-making seemingly predicated on the unsubstantiated mystery rate system employed (if a system even exists) by Defendants. And, again, whatever mystery Defendants’ re-pricing contract / formula / agreement / program that was employed by Defendants is outside of Exhibit A. To be clear, and again, this dispute revolves around the re-pricing established by Defendants separate and distinct from Exhibit A and SCV’s contention that the re-pricing contracts separate and distinct from Exhibit A that should have been employed (see Ex. C). To be clear, and again, the re-pricing dispute does not involve a substantive “interpretation of’ (or perhaps any “interpretation of”) Exhibit A. 18. Following the adverse Defendants’ claim underpayment via EOBs dated March 19, 2018, and October 31, 2018, appeals and / or reconsideration processes were timely carried out by SCV, culminating with SCV’s February 26, 2019, second level appeal letter and March 4, 2019, external review request. 19. As for Defendants, the pre-suit administrative appeals process culminated with Cigna’s March 8, 2019, letter, which stated, in pertinent part, as follows: “There’s no need for this appeal any longer. We’ve made the decision to approve coverage for the services you teceived.” Again, this is not a coverage dispute, this is a damages (i.e., rate of payment) dispute. 10 Filing 131905985 VS 05-2021-CA-039677-XXXX-XXTo be clear, SCV did not receive any additional payments from Defendants following the October 31, 2018, EOB and associated $9,546.00 payment from Defendants to SCV;"° i.e., it seems Defendants upheld their $38,967.90 payment decision, but we have no idea why or how. 20. Thereafter, undersigned counsel advised of his SCV representation and tequested production of various germane documents, which Cigna purports to have provided on Defendants’ behalves. See n. 4, supra. 21. Again, if one looks at the EOBs (which do not necessitate examination or “interpretation of” Exhibit A), it is plain that coverage is not at issue here — Defendants properly conceded coverage via initial partial payments. See Ex. F. And, again, as to the codes that SCV places at issue in this lawsuit, one can also look to the pre-authorization paperwork (which does not necessitate examination or “interpretation of’ Exhibit A) to see that coverage is not at issue here. See Ex. D (as stated earlier, Exhibit D shows that the subject pre-authorization put coverage issues to rest, leaving only pricing issues). Again, the sole issue here is one of payment amount, so we turn now to germane insurance policy language in that vein just for a baseline understanding (not at all for substantive reliance). 22. As to re-pricing, the insurance policy / Plan document (Ex. A) provides that payment of benefits is based on a MRC, as follows, in pertinent part: Cigna’s out-of-network coinsurance payments take into account what is ordinarily paid for a service or supply in the area where it is delivered. This maximum reimbursable charge (MRC) is used as the basis for determining the plan’s share of most out-of-network payments. Here’s how this works: « If an out-of-network provider charges less than the MRC for services delivered to you, coinsurance will be based on that lower amount 10 The March 19, 2018, EOB was coupled with a $29,421.90 payment from Defendants to SCV. 11 Filing 131905985 VS 05-2021-CA-039677-XXXX-XX¢ If an out-of-network provider charges in excess of the MRC, the plan’s reimbursement will be based on the MRC and you will owe your percentage of coinsurance plus whatever balance is due the provider. Ex. A at IV-16. The insurance policy / Plan document defines MRC as follows: The lesser of these two charges: the provider’s normal charge for a similar service or supply or a charge representing a percentage of what is ordinarily paid for a service or supply in a geographic area. The healthcare professional may bill the customer the difference between the healthcare professional’s normal charge and the MRC as determined by the benefit plan, in addition to applicable deductibles, copays and coinsurance. Id. at 1V-4 (emphasis in original). The “two charges” are exactly what PMCS and MultiPlan (Cigna’s repricing vendors) determine in establishing rate of payment. This is where the fleeting examination of Exhibit A would end in this case, which such fleeting examination does not rise to the level needed to establish “relation to” ERISA defensive preemption. 23. Again, where (as here) separate and distinct re-pricing contracts / agreements have been established to determine “the provider’s normal charge for a similar service” or “a charge representing a percentage of what is ordinarily paid for a service or supply in a geographic area,” see Ex. C, such a contract / agreement controls. Defendants’ own conduct evidences that much at least — Defendants implemented a mystery re-pricing contract / agreement / formula / program separate and distinct from Exhibit A, leading to the amounts of payment furnished under EOBs dated March 19, 2018, and October 31, 2018. So, Defendants should not now (through their lawyers’ ex post facto arguments) be heard to say that “relation to” defensive preemption applies to this dispute — at minimum, what is good for the goose is good for the gander; i.e., at minimum, waiver and / or estoppel are at play. 24. Defendants’ implementation of their mystery re-pricing contract / agreement / formula / program is untenable because SCV did not agree to same and, more importantly, the 12 Filing 131905985 VS 05-2021-CA-039677-XXXX-XXparties had previously agreed to rate of payment contracts (see Ex. C). 25. Once more, to date, it is unclear how Defendants ended up re-pricing the subject claim and / or why Defendants deviated from (or reneged on) the re-pricing contracts that had been established between the parties (see Ex. C). But what is clear is that this dispute tevolves around re-pricing contracts separate and distinct from the Plan document (Ex. A) and is accordingly not defensively preempted. 26. Defendants wronged SCV in many ways, most notably by way of the significant underpayment. Defendants should have employed the PMCS or MultiPlan re- pricing contracts (Ex. C) already in place (i.e., already agreed to between the parties) to assess a proper re-priced amount; but, instead, Defendants implemented a mystery re-pricing system (not agreed to by SCV) separate and distinct from Exhibit A to arrive at the rate of payment at issue. 27. Under the PMCS re-pricing analysis (which, again, was a re-pricing contract / agreement established by Cigna that SCV actually agreed to, along with the MultiPlan re- pricing contract / agreement established by Cigna that SCV actually agreed to, and unlike the Defendants’ mystery re-pricing contract / agreement / formula / program that Defendants unilaterally employed here without SCV’s agreement), for example,'! Defendants should have used an 80% rate to calculate the allowed amount equaling $211,156.00 (which such amount is 80% of all non-implant HCFA line-items and 100% of all implant HCFA line-items).'? This is the amount that the assumed patient responsibilities (capped at an annual out-of-pocket 1 “For example” because the MultiPlan re-pricing contract, see Ex. C, is also available for use by the trier of fact. !2 This PMCS-oriented re-price uses $246,382.00 as the billed amount; i.e., takes into consideration the line-items that SCV foregoes recovery on. See n. 7, supra. 13 Filing 131905985 VS 05-2021-CA-039677-XXXX-XXmaximum) should have been deducted from. The $211,156.00 less Defendants’ prior payment (which such prior payment presumably already took patient responsibilities subject to the annual out-of-pocket maximum into consideration) leaves an outstanding balance of $172,188.10 due and owing to SCV. This amount is exclusive of attorneys’ fees, costs, interest, and / or extra-contractual exposure. 28. SCV has suffered significant financial harm no matter how one slices this situation. The financial harm by way of owed medical services monies is in excess of $75,000.00, not including interest of attorneys’ fees, costs, or interest, if, for examples, the negotiated, agreed to 80% / 100% rate prescribed by Cigna’s third-party re-pricing vendor (PMCS) is honored / enforced as it should be, or even if rates prescribed by publicly available databases assessing the charges of providers of like kind within like geographies, like Agency for Health Care Administration (“AHCA”),'* were utilized in the re-pricing assessment. 29. SCV exhausted the pre-suit appeal process in an effort to accomplish Defendants’ doing the right thing (i.¢., properly compensating SCV) sans litigation, to no avail. Hence, this lawsuit as SCV’s regrettable last resort. COUNT I - BREACH OF CONTRACT (CLAIM UNDERPAYMENT) SCV re-alleges Paragraphs 1 through 29 as if fully set forth herein, and further alleges as follows. 30. At all material times to this action and in exchange for a valuable premium, Defendants provided health insurance to D.B. under the Plan document (Exhibit A). 13 See, eg, http:/Avww. floridahealthfinder. gov/LandingPages/HospitalASC.aspx and http://www. floridahealth finder.gov/CompareCare/SelectChoice.aspx. 14 Filing 131905985 VS 05-2021-CA-039677-XXXX-XX31. The subject medical services were covered under the Plan document, as evidenced by, for examples, (a) Defendants’ partial payment relating to same, (b) the Cigna- issued EOBs (Ex. F), (c) pre-authorization paperwork (Ex. D) approving the subject HCFA codes (Ex. E), and (d) et cetera. A fuller discussion as to why coverage is not at issue in this pure pricing dispute can be found in the above common allegations, namely Paragraphs 9-10. 32. Defendants erred in deciding to not fully compensate SCV by only tendering a $38,967.90 underpayment in relation to $246,382.00 in billed charges (see n. 12, supra) predicated on Defendants’ mystery re-pricing contract / agreement / formula / program separate and distinct from Exhibit A. As to all codes set forth on the HCFA (Ex. E), Defendants should have honored the re-pricing contracts (PMCS and / or MultiPlan) included in Exhibit C that the parties had actually already agreed to. Defendants’ payment amount comes nowhere close to the re-pricing formulas prescribed by PMCS (80% HCFA non-implant codes / 100% HCFA implant codes), for example. See § 27, supra. Defendants’ payment amount is accordingly in breach of the subject re-pricing contracts (Ex. C).!* 33. Defendants’ $38,967.90 underpayment does not constitute a usual, customary, teasonable re-priced / allowed amount no matter how one views the situation. First, for example, third-party repricing vendors who Cigna contracts with (e.g., PMCS, MultiPlan) have established SCV’s UCR (or MRC) based re-priced / allowed amount at 80% of billed charges (at least pursuant to PMCS in relation to non-implant HCFA line-items). Second, as another example, unbiased public databases (e.g., AHCA) assessing the rates of providers of like kind 4 And, again, at minimum, Defendants’ payment amount also does not come anywhere close to typical rates within the subject geography. Again, that kind of information can be easily found in the public domain through very reputable sources, see n. 13, supra. 15 Filing 131905985 VS 05-2021-CA-039677-XXXX-XXwithin like Florida geographies make clear that Defendants’ unsubstantiated rate of payment does not find support amidst UCR rates relating to providers of like kind within like Florida geographies. 34, Defendants, among other things, had a duty to properly investigate the subject medical services, adjust / investigate the subject SCV claim relating to such services, and fully compensate SCV in relation to same. Defendants failed SCV in these regards (most notably with respect to their failure to pay the monies due and owing under the subject re-pricing contracts), which breached the subject re-pricing contracts / agreements and / or violated Florida law. 35, As a direct, foreseeable, and proximate result of Defendants’ breach of their obligations under the re-pricing contracts, SCV has suffered and continues to suffer damages. 36. SCV has no other adequate remedy other than this lawsuit to address the injuries it has suffered as a result of Defendants’ underpayment of the monies owed to it in telation to the subject D.B. medical services. 37. As a further result of Defendants’ refusal to fully compensate SCV, SCV has been forced to retain legal counsel to represent it in this matter and is accordingly entitled to recover its reasonable attorneys’ fees and costs pursuant to Section 627.428 of the Florida Statutes or as otherwise awardable. WHEREFORE, Plaintiff, Surgery Center of Viera, LLC, requests the entry of judgment against Defendants, Cigna Health and Life Insurance Company, Harris Corporation Group Insurance Plan, and Harris Corporation, for liability and for damages including, but not limited to, (a) past-due contractual monies owed in relation to the subject medical services and all 16 Filing 131905985 VS 05-2021-CA-039677-XXXX-XXassociated awardable accrued interest, (b) attorneys’ fees pursuant to Section 627.428 of the Florida Statutes or as otherwise awardable, (c) costs incurred bringing this action, and (d) for such other relief as this Court deems equitable, just and proper. COUNT II —- UNJUST ENRICHMENT SCV re-alleges Paragraphs 1 through 29 as if fully set forth herein, and further alleges as follows. 38. SCV conferred a direct benefit on Defendants by providing Defendants’ insured / member (D.B.) with medical services to which the insured was entitled under the insurance policy (covered) as evidenced by Defendants’ partial payment. Examples of “conferral of benefit” would include the following, for examples, which are posed as questions: (a) What about Defendants receiving the benefit when their policyholder / employee received care and treatment offering Defendants’ insurance policy as their primary method of payment? (b) What about the good health of D.B. conferred on Defendants? Was it not of benefit to Defendants that SCV minimized (if not entirely eliminated, actually) D.B.’s future medical expense (and insurance claims to Defendants) relating to the subject conditions such as prolonged alternative treatments or a return for more (and perhaps more complex) surgery due to complications arising out of some other inferior treatment regimen? 39. Defendants voluntarily accepted and received the benefit conferred by SCV, with the knowledge that SCV expected to be paid the reasonable value of its services; i.e., SCV’s usual, customary, reasonable charges as prescribed by reasonable, negotiated re-pricing vendors (e.g., PMCS, MultiPlan) or, for that matter, as prescribed by Florida’s publicly available AHCA database assessing rates of various medical providers of like kind within like 17 Filing 131905985 VS 05-2021-CA-039677-XXXX-XXgeography. Again, as to Defendants’ knowledge, there are several things supportive of same in the above common allegations; e.g., the pre-authorization process, SCV’s claim submission package cover letter and HCFA, the parties’ past dealings with each other, and et cetera. 40. Defendants voluntarily accepted and received the benefit conferred by SCV, with the knowledge (through course of past dealings with SCV that included claim submission cover letters such as that attached as Exhibit G indicating re-pricing contract expectations, or otherwise) that SCV expected to be paid the reasonable value of its services; i.¢., SCV’s UCR charges as prescribed by reasonable re-pricing vendors (e.g., PMCS, MultiPlan) or, for that matter, as prescribed in the Florida’s publicly available AHCA database assessing rates of various medical providers of like kind within like geography. 41. Defendants have not paid the value of the benefit conferred by SCV in that Defendants have significantly underpaid SCV’s claim for monies owed in relation to the medical services provided to D.B. 42. Defendants’ underpayment results in a windfall for Defendants in that (a) Defendants collect premiums in return for agreeing to properly compensate providers, like SCV, who render covered medical services, and / or (b) Defendants enjoy an unearned profit in relation to the insurance benefits themselves, in relation to interest that has accrued on the wrongly withheld benefits, in relation to investment returns enjoyed through the monies wrongly withheld from SCV, in relation to level-funded plan profits enjoyed through the wrongly withheld monies, and / or et cetera. 43. It is unjust under the circumstances for Defendants to underpay SCV’s claim. 44. SCV has no other adequate remedy other than this lawsuit to address the 18 Filing 131905985 VS 05-2021-CA-039677-XXXX-XXinjuries it has suffered as a result of Defendants’ underpayment of the monies owed to it in relation to the subject medical services. 45. As a further result of Defendants’ refusal to fully compensate SCV, SCV has been forced to retain legal counsel to represent it in this matter and is accordingly entitled to tecover its reasonable attorneys’ fees and costs pursuant to Section 627.428 of the Florida Statutes or as otherwise awardable. WHEREFORE, Plaintiff, Surgery Center of Viera, LLC, requests the entry of judgment against Defendants, Cigna Health and Life Insurance Company, Harris Corporation Group Insurance Plan, and Harris Corporation, for liability and for damages including, but not limited to, (a) past-due monies owed for the subject medical services and all associated awardable accrued interest, (b) attorneys’ fees pursuant to Section 627.428 of the Florida Statutes or as otherwise awardable, (c) costs incurred bringing this action, and (d) for such other relief as this Court deems equitable, just and proper. COUNT II —- QUANTUM MERUIT SCV re-alleges Paragraphs 1 through 29 as if fully set forth herein, and further alleges as follows. 46. SCV conferred a direct benefit on Defendants by providing Defendants’ insured / member (D.B.) with medical services to which the insured was entitled under the insurance policy (covered) as evidenced by Defendants’ partial payment. Examples of “conferral of benefit” (in the form of questions) are discussed in Paragraph 38, supra, and incorporated into this count by reference. 19 Filing 131905985 VS 05-2021-CA-039677-XXXX-XX47. SCV billed Defendants its UCR charges for the services as prescribed by reasonable re-pricing vendors (e.g., PMCS, MultiPlan) or, for that matter, as prescribed by Florida’s publicly available AHCA database assessing rates of various medical providers of like kind within like geography. The billed charges represent the fair market value of the services rendered. 48. Defendants received the bill from SCV but underpaid SCV for the services. 49. Animplied contract was doubtless established through Defendants’ knowledge that services were being rendered and both sides intended for compensation to be paid, with the parties possessing the compensation intention through the course of their past dealings (such as through claim submission letters like Exhibit G routinely furnished to Cigna indicating SCV’s expectation to be paid pursuant to the subject re-pricing contracts) or otherwise. 50. In order for the implied contract to have been formed, Defendants did not have to be the recipient of the services or request the services. 51. SCV is entitled to reasonable compensation for the services (i.e., quantum meruit), which is by no means accomplished by Defendants’ unsubstantiated rate of payment but is reflected in reasonable sources such as third-party re-pricing vendors’ (e.g., PMCS, MultiPlan) or Florida’s publicly available AHCA databases of assessments of SCV’s rates. And determination of the proper amount of compensation is a question of fact reserved for a jury. 52. The circumstances are such that it would be inequitable for Defendants to retain the benefit of the subject medical services without paying SCV the proper value for same. 20 Filing 131905985 VS 05-2021-CA-039677-XXXX-XX53. SCV has no other adequate remedy other than this lawsuit to address the injuries it has suffered as a result of Defendants’ underpayment of the monies owed to it in relation to the subject medical services. 54. Asa further result of Defendants’ refusal to fully compensate SCV, SCV has been forced to retain legal counsel to represent it in this matter and is accordingly entitled to recover its reasonable attorneys’ fees and costs pursuant to Section 627.428 of the Florida Statutes or as otherwise awardable. WHEREFORE, Plaintiff, Surgery Center of Viera, LLC, requests the entry of judgment against Defendants, Cigna Health and Life Insurance Company, Harris Corporation Group Insurance Plan, and Harris Corporation, for liability and for damages including, but not limited to, (a) past-due monies owed for the subject medical services and all associated awardable accrued interest, (b) attorneys’ fees pursuant to Section 627.428 of the Florida Statutes or as otherwise awardable, (c) costs incurred bringing this action, and (d) for such other relief as this Court deems equitable, just and proper. JURY DEMAND 55. Plaintiff, Surgery Center of Viera, LLC, demands a trial by jury on all issues so triable as a matter of right. Dated: July 21, 2021 21 Filing 131905985 VS 05-2021-CA-039677-XXXX-XXRespectfully Submitted, CALLAGY LAW, P.C. 1900 N.W. Corporate Blvd., Ste 310W Boca Raton, Florida 33431 (561) 405-7966 (0); (201) 549-8753 (f) /s/ Jeffrey L. Greyber Jeffrey L. Greyber, Esq. Fla. Bar No. 41103 jgreyber@callagylaw.com hcasebolt@callagylaw.com Attorney for Plaintiff 22 Filing 131905985 VS 05-2021-CA-039677-XXXX-XXExhibit A Filing 131905985 VS 05-2021-CA-039677-XXXX-XXHarris Corporation OPEN ACCESS PLUS MEDICAL BENEFITS OAP 850/1700 Active Employees EFFECTIVE DATE: January 1, 2017 ASO28 (OAP3) 3337001 This document printed in April, 2017 takes the place of any documents previously issued to you which described your benefits. Printed in U.S.A. Filing 131905985 VS 05-2021-CA-039677-XXXX-XXFiling 131905985 VS 05-2021-CA-039677-XXXX-XXTable of Contents Important Information. Special Plan Provisions. seve Important Notices ... How To File Your Claim .....sssssscsrsenssesssessscssnacssesnssssenaseranesavesenesrenees Eligibility - Effective Date........ soesnees coveconssennenesensossesssvesavcesnecossceausenuecassconsconscosssonesennonsseesvedtiiesD) Employee Insurance . 9 Waiting Period...... Dependent Insurance... Important Information About Your Medical Plan... Open Access Plus Medical Benefits ........sssssssssssssessessesosensssesnessnpssesenseeasnessseannesterssneensnannsnrenrsord The Schedule ..... wool Certification Requirements - Out-of-Network 24 Prior Authorization/Pre-Authorized .... Covered Expenses .... .24 wee DS Exclusions, Expenses Not Covered and General Limitations ........:csseeneceeeeeeneenenn dd Coordination of Benefits... ssesensavacoenazerennequsdannnneareperesennnennere Expenses For Which A Third Party May Be Responsible vessoseone ssrneeansesnseeneeeane DD Payment of Benefits ......csesesssesesssessesserevn Termination of Insurance... Employees...... Dependents Rescissions Federal Requirements .........s00 Notice of Provider Directory/Networks.... Qualified Medical Child Support Order (QMCSO) .. Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) Effect of Section 125 Tax Regulations on This Plan...... Eligibility for Coverage for Adopted Children Coverage for Maternity Hospital Stay...... Women’s Health and Cancer Rights Act (WHCRA) Group Plan Coverage Instead of Medicai Requirements of Medical Leave Act of 1993 (as amended) (FMLA) Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) Claim Determination Procedures under ERISA...... Medical - When You Have a Complaint or an Appeal COBRA Continuation Rights Under Federal Law..... ERISA Required Information....... Definitions .......sccseseersesees Filing 131905985 VS 05-2021-CA-039677-XXXX-XXImportant Information THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY HARRIS CORPORATION WHICH IS RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY (CIGNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT INSURE THE BENEFITS DESCRIBED. THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CIGNA," "INSURANCE COMPANY," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR "EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND "INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE." HC-NoTt Filing 131905985 VS 05-2021-CA-039677-XXXX-XXExplanation of Terms You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms are defined in the Definitions section of your certificate, The Schedule The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description of each benefit, refer to the appropriate section listed in the Table of Contents. Filing 131905985 VS 05-2021-CA-039677-XXXX-XXSpecial Plan Provisions When you select a Participating Provider, this Plan pays a greater share of the costs than if you select a non-Participating Provider, Participating Providers include Physicians, Hospitals and Other Health Care Professionals and Other Health Care Facilities. Consult your Physician Guide for a list of Participating Providers in your area. Participating Providers are committed to providing you and your Dependents appropriate care while lowering medical costs. Services Available in Conjunction With Your Medical Plan The following pages describe helpful services available in conjunction with your medical plan. You can access these services by calling the toll-free number shown on the back of your ID card. HC-SPP 04-16 vl Case Management Case Management is a service provided through a Review Organization, which assists individuals with treatment needs that extend beyond the acute care setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a Hospital or specialized facility. Should the need for Case Management arise, a Case Management professional will work closely with the patient, his or her family and the attending Physician to determine appropriate treatment options which will best meet the patient's needs and keep costs manageable. The Case Manager will help coordinate the treatment program and arrange for necessary resources, Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis. Case Managers are Registered Nurses (RNs) and other credentialed health care professionals, each trained in a clinical specialty area such as trauma, high risk pregnancy and neonates, oncology, mental health, rehabilitation or general medicine and surgery. A Case Manager trained in the appropriate clinical specialty area will be assigned to you or your dependent. In addition, Case Managers are supported by a panel of Physician advisors who offer guidance on up-to- date treatment programs and medical technology. While the Case Manager recommends alternate treatment programs and helps coordinate needed resources, the patient's attending Physician remains responsible for the actual medical care. You, your dependent or an attending Physician can request Case Management services by calling the toll-free number shown on your ID card during normal business hours, Monday through Friday. In addition, your employer, a claim office or a utilization review program (see the PAC/CSR. section of your certificate) may refer an individual for Case Management. The Review Organization assesses each case to determine whether Case Management is appropriate. You or your Dependent is contacted by an assigned Case Manager who explains in detail how the program works. Participation in the program is voluntary - no penalty or benefit reduction is imposed if you do not wish to participate in Case Management. Following an initial assessment, the Case Manager works with you, your family and Physician to determine the needs of the patient and to identify what alternate treatment programs are available (for example, in-home medical care in lieu of an extended Hospital convalescence). You are not penalized if the alternate treatment program is not followed. . . The Case Manager arranges for alternate treatment services and supplies, as needed (for example, nursing services or a Hospital bed and other Durable Medical Equipment for the home). The Case Manager also acts as a liaison between the insurer, the patient, his or her family and Physician as needed (for example, by helping you to understand a complex medical diagnosis or treatment plan). Once the alternate treatment program is in place, the Case Manager continues to manage the case to ensure the treatment program remains appropriate to the patient's needs. While participation in Case Management is strictly voluntary, Case Management professionals can offer quality, cost- effective treatment alternatives, as well as provide assistance in obtaining needed medical resources and ongoing family support in a time of need. . . HC-SPP2 08-40 vi Additional Programs We may, from time to time, offer or arrange for various entities to offer discounts, benefits, or other consideration to our members for the purpose of promoting the general health and well being of our members. We may also arrange for the reimbursement of all or a portion of the cost of services Filing 131905985 VS myCigna.com 05-2021-CA-039677-XXXX-XXwie ne Né Cigna. provided by other parties to the Policyholder. Contact us for details regarding any such arrangements. HC-SPPS onto Care Management and Care Coordination Services Your plan may enter into specific collaborative arrangements with health care professionals committed to improving quality care, patient satisfaction and affordability. Through these collaborative arrangements, health care professionals commit to proactively providing participants with certain care management and care coordination services to facilitate achievement of these goals. Reimbursement is provided at 100% for these services when rendered by designated health care professionals in these collaborative arrangements. ue-spP27 06-13 vi Important Notices Direct Access to Obstetricians and Gynecologists You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit www. mycigna.com or contact customer service at the phone number listed on the back of your ID card. Selection of a Primary Care Provider This plan gener