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Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 1 of 31
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Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 3 of 31
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FORM 1.997. CIVIL COVER SHEET

The civil cover sheet and the information contained in it neither replace nor supplement the filing

and service of pleadings or other documents as required by law. This form must be filed by the

plaintiff or petitioner with the Clerk of Court for the purpose of reporting uniform data pursuant

to section 25.075, Florida Statutes. (See instructions for completion.)

I. CASE STYLE

IN THE CIRCUIT/COUNTY COURT OF THE ELEVENTH JUDICIAL CIRCUIT,

IN AND FOR MIAMI-DADE COUNTY, FLORIDA

PALMETTO EKG & ECHO READERS, P.A.

Plaintiff Case #

Judge

vs.

CIGNA HEALTHCARE OF FLORIDA, INC.,

Defendant

II. AMOUNT OF CLAIM

Please indicate the estimated amount of the claim, rounded to the nearest dollar. The estimated amount of

the claim is requested for data collection and clerical processing purposes only. The amount of the claim

shall not be used for any other purpose. 

 ☒ $8,000 or less

☐ $8,001 - $30,000

☐ $30,001- $50,000

☐ $50,001- $75,000

☐ $75,001 - $100,000

☐ over $100,000.00

III. TYPE OF CASE (If the case fits more than one type of case, select the most

definitive category.) If the most descriptive label is a subcategory (is indented under a broader

category), place an x on both the main category and subcategory lines.

Filing # 152763517 E-Filed 07/06/2022 11:42:10 AM Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 4 of 31
- 2 -

CIRCUIT CIVIL

☐ Condominium

☐ Contracts and indebtedness

☐ Eminent domain

☐ Auto negligence

☐ Negligence—other

☐ Business governance

☐ Business torts

☐ Environmental/Toxic tort

☐ Third party indemnification

☐ Construction defect

☐ Mass tort

☐ Negligent security

☐ Nursing home negligence

☐ Premises liability—commercial

☐ Premises liability—residential

☐ Products liability

 ☐ Real Property/Mortgage foreclosure

☐ Commercial foreclosure

☐ Homestead residential foreclosure

☐ Non-homestead residential foreclosure

☐ Other real property actions

☐Professional malpractice

☐ Malpractice—business

☐ Malpractice—medical

☐ Malpractice—other professional

☐ Other

☐ Antitrust/Trade regulation

☐ Business transactions

☐ Constitutional challenge—statute or ordinance

☐ Constitutional challenge—proposed amendment

☐ Corporate trusts

☐ Discrimination—employment or other

☐ Insurance claims

☐ Intellectual property

☐ Libel/Slander

☐ Shareholder derivative action

☐ Securities litigation

☐ Trade secrets

☐ Trust litigation

COUNTY CIVIL

☒ Small Claims up to $8,000

☐ Civil

☐ Real property/Mortgage foreclosure 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 5 of 31
- 3 -

☐ Replevins

☐ Evictions

☐ Residential Evictions

☐ Non-residential Evictions

☐ Other civil (non-monetary)

COMPLEX BUSINESS COURT

This action is appropriate for assignment to Complex Business Court as delineated and mandated by the

Administrative Order. Yes ☐ No ☒

IV. REMEDIES SOUGHT (check all that apply):

☒ Monetary;

☐ Nonmonetary declaratory or injunctive relief;

☐ Punitive

V. NUMBER OF CAUSES OF ACTION: [ ]

(Specify)

3

VI. IS THIS CASE A CLASS ACTION LAWSUIT?

☐ yes

☒ no

VII. HAS NOTICE OF ANY KNOWN RELATED CASE BEEN FILED?

☒ no

☐ yes If “yes,” list all related cases by name, case number, and court.

VIII. IS JURY TRIAL DEMANDED IN COMPLAINT?

☒ yes

☐ no

IX. DOES THIS CASE INVOLVE ALLEGATIONS OF SEXUAL ABUSE?

☐ yes

☒ no

I CERTIFY that the information I have provided in this cover sheet is accurate to the best of

my knowledge and belief, and that I have read and will comply with the requirements of

Florida Rule of Judicial Administration 2.425.

Signature: s/ Mark Lawrence Rosen Fla. Bar # 45675

Attorney or party (Bar # if attorney)

Mark Lawrence Rosen 07/06/2022

(type or print name) Date

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 6 of 31
16015-C005

IN THE COUNTY COURT IN AND FOR 

MIAMI-DADE COUNTY, FLORIDA

CASE NO.: 

PALMETTO EKG & ECHO READERS,

PROFESSIONAL ASSOCIATION, a 

Florida Corporation (o/b/o Member # 

U0536350801),

Plaintiff,

v. 

CIGNA HEALTHCARE OF FLORIDA, 

INC., a Florida corporation, 

Defendant.

_____________________________________/ 

COMPLAINT

Plaintiff, PALMETTO EKG & ECHO READERS, PROFESSIONAL ASSOCIATION 

o/b/o Member # U0536350801 (“Palmetto EKG” or “Plaintiff”), sues Defendant, CIGNA 

HEALTHCARE OF FLORIDA, INC., Florida not for profit corporation (“Cigna” or

“Defendant”), and alleges as follows: 

GENERAL ALLEGATIONS

A. Jurisdiction, Venue and Parties

1. This is an action for damages to recover underpaid healthcare claims pursuant to

Florida Statute § 641.3155/Section 641.3156 and for other relief requested herein between $100.00 

and $500.00, exclusive of court costs, pre-judgment interest, and attorney fees.

2. Plaintiff is a Florida for-profit corporation doing business in Miami-Dade County 

with its principal place of business in Miami-Dade County, Florida. 

3. At all times material hereto, Plaintiff was and is a healthcare provider duly licensed 

and authorized by the State of Florida to provide healthcare and treatment therein. 

Filing # 152763517 E-Filed 07/06/2022 11:42:10 AM Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 7 of 31
4. Defendant Cigna is a Florida for-profit corporation with its headquarters at 2701 

North Rocky Point Drive, Tampa, Florida 33607 and is licensed as a health maintenance

organization (“HMO”) pursuant to Chapter 641 of the Florida Statutes. Cigna provides managed

care products and administrative services throughout Florida, including Miami-Dade County, 

Florida, and has an office for the transaction of its customary business in Miami-Dade County, 

Florida. 

5. Defendant Cigna contracts to insure persons or risks located within the State of 

Florida, including Miami-Dade County, at the time of contracting, and therefore this Court has 

subject matter jurisdiction pursuant to Fla. Stat. § 48.193(1)(a)(4). 

6. All services were performed in Miami-Dade County and billed from Plaintiff’s

principal of place of business. 

7. Palmetto General Hospital (not a party to thissuit) is an acute care facility located in 

Miami-Dade County, is a contracted facility with Cigna and is where the medical services 

described in this Complaint were provided. 

8. Plaintiff Palmetto EKG is required to interpret medically necessary

electrocardiograms (“EKGs”) and echocardiograms (“ECHOs”) to patients who present to

Palmetto General Hospital. 

9. Plaintiff is obligated by Florida law to provide medical services to any individual 

presenting to the emergency department, regardless of the individual’s insurance coverage or 

ability to pay. 

10. Member # U0536350801 (“Member” or “Subscriber”) is a fictitious name for the

patient who is covered under Defendant’s Policy of Insurance and who received the medical

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 8 of 31
services described in this Complaint. Upon information and belief, Member can be identified by 

Cigna as Member or Subscriber ID # U0536350801. 

11. Plaintiff provided emergency and/or nonemergency services and medical care to

Defendant’s Member at Palmetto General Hospital (not a party to this suit), an acute care facility

licensed under Chapter 395, and has the requisite standing to bring this private first party action

against the Defendant. See Merkle v. Health Options, Inc., 940 So. 2d 1190, 1194 (Fla. 4th DCA

2006). Upon information and belief, said facility, at all times material, had a contract with

Defendant Cigna. 

12. This action does not include any claims in which benefits which were denied nor 

does it challenge any coverage determinations under an ERISA plan. 

13. Venue is proper in Miami-Dade County, Florida, pursuant to Chapter 47, Florida 

Statutes, because all services were performed in Miami-Dade County and billed from Plaintiff’s

principal of place of business. 

B. The Covered Services

14. In exchange for premiums, Defendant pays for health care services rendered to 

members of its commercial health care products and platforms, including exchange products, selfinsurance plans, health maintenance organizations, prefered provider organizaitons, exclusive

provier organizations, limited health service organizations, indemnity plans, or any health care 

arrangement whereby risk is assumed. 

15. Defendant is a health insurer who operates a health maintenance organization 

(“HMO”) as defined by Florida Statute § 641.19(12). HMOs are governed by Chapter 641 of the 

Florida Statutes.

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 9 of 31
16. Defendant was paid a premium by or on behalf of Member in exchange for 

healthcare coverage according to the terms of the policy. 

17. Upon information and belief, at all times material Palmetto General Hospital had

and has a contractual agreement with Cigna by which Palmetto General Hospital agreed to

participate in Defendant’s network of participating facilities to provide medical services to

subscribing members covered by Defendant’s health plans. 

18. At all times material, Plaintiff had no direct agreement with Cigna to be reimbursed

for its services provided to Defendant’s subscribing members at discounted rates. Accordingly, 

Plaintiff was and is considered an out-of-network or nonparticipating provider with Cigna. 

19. Member is covered by Defendant’s Florida-licensed HMO insurance policy (the

“Policy” or “Agreement”) which was in full force and effect at the time of the medical services

provided herein. Plaintiff is not in possession of Member’s Policy; however, Defendant is, or 

should be, in possession of Member’s Policy and such will be obtained via discovery. 

20. On 7/10/2018, Member had an emergent and/or non-emergent electrocardiogram

(“EKG”) and/or echocardiogram (“ECHO”) tests performed at Palmetto General Hospital. 

21. Member did not have the ability or opportunity to choose a participating in-network

provider at Palmetto General Hospital, who was available to perform the medical services

performed by Plaintiff during Member’s treatment at Palmetto General Hospital.

22. All medical services provided by Plaintiff were reasonable and medically necessary

in light of Member’s presenting condition. 

23. The medical services provided by Plaintiff to Member are covered services under 

the Policy. 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 10 of 31
24. Florida law mandates that out-of-network providers be paid for the services they 

render in both emergent and non-emergent circumstances under certain conditions. See Florida 

Statutes § 641.513(5) and § 641.3156(1). 

Florida Statute Section 641.513(5) 

25. If Member’s treatment was emergent, payment of Plaintiff’s claim is governed by 

§ 641.513(5) which provides: 

Reimbursement for services pursuant to this section by a provider who does 

not have contract with the health maintenance organization, shall be the lesser 

of:

(a) The provider's charges;

(b) The usual and customary provider charges for similar services 

in the community where the services were provided; or

(c) The charge mutually agreed to by the health maintenance 

organization and the provider within 60 days of the submittal of 

the claim. (Emphasis Added).

Florida Statute Section 641.3156(1) 

26. If Member’s treatment was non-emergent, payment of Plaintiff’s claim is governed 

by § 641.3156 which provides: 

(1) A health maintenance organization must pay any hospital-service or 

referral-service claim for treatment for an eligible subscriber which was 

authorized by a provider empowered by contract with the health 

maintenance organization to authorize or direct the patient’s utilization of 

health care services and which was also authorized in accordance with the 

health maintenance organization’s current and communicated 

procedures, unless the provider provided information to the health 

maintenance organization with the willful intention to misinform the 

health maintenance organization. (Emphasis Added). 

27. Plaintiff timely and properly submitted its claim for medical services to Cigna in the 

usual course of business for reimbursement of the covered services, in the amount of $554.00.

Rather than paying Plaintiff’s charges, Defendant paid only $102.80 for the medical services 

provided, an amount which is less than what is required by Florida law and the Policy. 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 11 of 31
28. Plaintiff’s billed charges for the covered medical services it provided to Defendant’s 

Member were within, and are actually less than less than, the usual and customary charges for the 

community or geographic area based on what providers in the area usually charge for the same or 

similar medical services.

29. Accordingly, Plaintiff is entitled to full reimbursement of its billed charges for the 

medical services provided to Member, as that rate is within the usual and customary charges for 

the community or geographic area. 

30. In the alternative, if Plaintiff’s billed charges for the medical services provided to 

Member are determined to be in excess of the usual and customary charges for Miami-Dade 

County, the community or geographic area, Plaintiff is entitled to reimbursement for the usual and 

customary charges for the community or geographic area. 

31. Defendant has wrongfully refused to pay Plaintiff the entire amount of Plaintiff’s 

billed charges on the submitted claims.

32. Defendant, by paying an arbitrary amount, has wrongfully refused to pay Plaintiff 

the usual and customary charges on the submitted claims. Rather, the rate paid by Defendant was 

significantly less than usual and customary charges. 

33. As a result of the underpayment, Plaintiff has been damaged. 

34. Plaintiff is entitled to interest thereon at a rate 12% per annum on the amounts 

overdue on the underpaid claims pursuant to § 641.3155(6), Florida Statutes.

35. Plaintiff has retained the undersigned law firm to represent its interests in this 

matter. Plaintiff has agreed to pay, and counsel for Plaintiff has agreed to accept, any Court 

awarded fee for its reasonable attorney fees and costs.

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 12 of 31
36. All available conditions precedent relative to this action have been performed or 

satisfied by Plaintiff or waived by Defendant. 

C. Plaintiff’s claims do not implicate Section 502(a) of ERISA

37. To the extent that the Policy could be governed by an Employee Retirement Income

Security Act of 1974 (“ERISA”) plan, Plaintiff’s claims against Cigna are solely for breach of the 

Provider Agreements and Plaintiff expressly disclaims any claims for violations of ERISA. 

38. Plaintiff's claims concern only rate of payment, rather than right of payment claims. 

These claims are based on contractual principles that are outside the scope of section 502(a) of 

ERISA, and are not completely preempted by ERISA. See Connecticut State Dental Ass'n v. 

Anthem Health Plans, Inc., 591 F.3d 1337, 1350 (11th Cir. 2009); See also Hialeah Anesthesia 

Specialists, LLC v. Coventry Health Care of Florida, Inc., 258 F. Supp. 3d 1323, 1330 (S.D. Fla. 

2017).1 2

39. Plaintiff’s claims in this action do not include any claims in which benefits which 

were denied nor does it challenge any coverage determinations under an ERISA plan. 

40. Plaintiff’s claims do not implicate any Federal law and no claims made herein 

1

 See Final Order of Remand at 4–5, Recovery Vill. at Umatilla, LLC v. United Behavioral 

Health, Inc., No. 15–62374, ECF No. 37 (S.D. Fla. Sept. 12, 2016) (Finding “because Plaintiff's 

claims are rate of payment, rather than right of payment claims, and because they are based on 

contractual principles beyond the scope of ERISA, these claims are not completely preempted by 

ERISA”); See also Order Granting Pl.'s Mot. to Remand at 5, Recovery Vill. at Umatilla, LLC v. 

Blue Cross & Blue Shield of Fla., Inc., No. 15–61414, ECF No. 52 (S.D. Fla. Aug. 28, 2015) (“If 

all the claims at issue were pre-authorized and paid by Defendants, as Plaintiff contends, such 

claims would not fall within the scope of ERISA, and [the plaintiff]'s state-law claims would not 

be completely preempted.... [T]he Court must resolve doubt regarding its subject-matter 

jurisdiction in favor of remand.”). 

2

 See also Blue Cross of Cal. v. Anesthesia Care Assocs. Med. Grp., Inc., 187 F.3d 1045, 

1051 (9th Cir. 1999) (“[T]he bare fact that the [ERISA] plan may be consulted in the course of 

litigating a state-law claim does not require that the claim be extinguished by ERISA's enforcement 

provision.”). 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 13 of 31
would give rise to Federal Jurisdiction. 

COUNT I- Violation Of Florida Statute Section 641.513(5) 

41. Plaintiff realleges the General Allegations (paragraphs 1-40) as if fully set forth

herein.

42. At all times material hereto, Plaintiff and Defendant did not have a network 

agreement between them governing the rates at which Defendant must reimburse Plaintiff for its 

services, thus Plaintiff is an out-of-network provider. 

43. On or about 7/10/2018, Member initiated care and received emergency and/or 

nonemergency medical services from Plaintiff and Plaintiff’s physicians at Palmetto General 

Hospital. 

44. Plaintiff timely and directly submitted to Defendant claims for payment for medical 

services provided to Member in the amount of $554.00 for medical services rendered by Plaintiff 

to Member during their hospitalization which began on 7/10/2018. Rather than paying Plaintiff’s 

charges, or in the alternative if Plaintiff’s charges are determined to exceed the usual and 

customary provider charges, the usual and customary charges Defendant would be required to pay, 

Defendant paid only $102.80 for the medical services provided, a sum far below the usual and 

customary provider charges for the community or geographic area. 

45. Section 641.513 requires HMOs insurance companies, such as Defendant, to 

reimburse “nonparticipating” or “Out-of-network” providers for covered emergency and nonemergency services pursuant to Section 641.513, Florida Statutes. 

46. Section 641.513, Florida Statutes, requires HMOs to properly reimburse providers 

for rendering emergency and nonemergency services, such as the services rendered by Plaintiff.

47. Emergency services rendered by out of network providers must be reimbursed

according to the following schedule found in § 641.513(5)(a)-(c):

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 14 of 31
(5) Reimbursement for services pursuant to this section by a provider

who does not have a contract with the [HMO] shall be the lesser of: 

(a) The provider’s charges;

(b) The usual and customary provider charges for similar

services in the community where the services were provided; or 

(c) The charge mutually agreed to by the [HMO] and the

provider within 60 days of the submittal of the claim. (Emphasis 

Added). 

48. If Member’s treatment was non-emergent, payment of Plaintiff’s claim is governed 

by § 641.3156 which provides: 

(2) A health maintenance organization must pay any hospital-service or 

referral-service claim for treatment for an eligible subscriber which was 

authorized by a provider empowered by contract with the health 

maintenance organization to authorize or direct the patient’s utilization of 

health care services and which was also authorized in accordance with the 

health maintenance organization’s current and communicated 

procedures, unless the provider provided information to the health 

maintenance organization with the willful intention to misinform the 

health maintenance organization. (Emphasis Added). 

49. Thus, Defendant is required to pay the Plaintiff the lesser of Plaintiff’s billed

charges and the usual and customary charges for similar services in the community where the 

services were provided for the emergency and/or nonemergency medical services Plaintiff

rendered to Member.

50. Florida Statute Section 641.513(5) is incorporated into Member’s HMO policy. 

51. The provisions of Fla. Stat. § 641.513(5) may not be waived, voided, or nullified

by contract.

52. Cigna’s failure to timely and properly pay the subject claims or the 12% interest is

a breach of Member’s HMO policy. 

53. As a direct and proximate result of Defendant’s violation of Fla. Stat. § 641.513(5), 

Plaintiff has suffered damages in the form of outstanding balance for its charges for medical

services plus 12 percent interest.

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 15 of 31
54. Defendant has wrongfully refused to pay Plaintiff its billed charges or the usual and

customary charges on the submitted claims in violation of Chapter 641, Florida Statutes.

55. As a direct and proximate result of Defendant’s violation of the statute, Plaintiff

has suffered damages in the amount of the unpaid balance for its billed charges which are within

the usual and customary charges for the medical service provided or, in the alternative, what is

determined to be the usual and customary charges for the medical services provided, together with

prejudgment interest and its reasonable attorney fees pursuant to §§ 641.28 and 641.3155(6), 

Florida Statutes.

WHEREFORE, Plaintiff demands judgment against Defendant Cigna for the unpaid 

balance of its full billed charges, as same are within the usual and customary charges, or in the 

alternative, if Plaintiff’s billed charges are determined to be in excess of the usual and customary

charges for the community or geographic area, Plaintiff demands judgment for the unpaid usual 

and customary charges for the community or geographic area for its emergency and nonemergency

charges for the medical services rendered, together with pre-judgment interest and its reasonable

attorney fees and costs pursuant to §§ 641.28 and 641.3155(6), Florida Statutes, and such other 

relief as the Court deems just and proper. 

Count II - Breach Of Third-Party Beneficiary Contract

56. Plaintiff realleges the General Allegations (paragraphs 1-40) as if fully set forth

herein.

57. At all times relevant, Member, while a patient at Palmetto General Hospital,

received emergency and/or nonemergency services from Plaintiff under the terms of the Policy. 

58. Plaintiff is a third-party beneficiary to the Policy since Defendant is mandated to

pay Plaintiff directly for such services pursuant to Florida law.

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 16 of 31
59. Plaintiff is also a third-party beneficiary to the Policy since (i) Florida law

recognizes that medical service providers are intended beneficiaries of insurance contracts;

(ii) such contracts primarily and directly benefit medical providers such as Plaintiff pursuant to

Florida statutes incorporated within the insurance contracts by the statutory incorporation doctrine; 

and (iii) because the insurance contracts either mandated or allowed for payment directly to

Plaintiff for the services that were provided to Member. 

60. The Policy between Defendant and Member should be interpreted to provide that

Defendant should pay Plaintiff its billed charges or, in the alternative, the usual and customary

charges for the medical services rendered, if it is determined that the billed charges exceed the 

usual and customary charges for the medical services rendered. Alternatively, the charges for

services rendered by Plaintiff are either set by statute or administrative regulation, which is

incorporated into the contract through the principle of statutory incorporation. 

61. Moreover, at all times material, Defendant has acted as though Plaintiff was and is 

a third-party beneficiary thereby waiving any anti-third-party beneficiary clause(s) in its Policy.

62. Member is enrolled in Defendant’s HMO and as such Member’s policy is governed 

by Florida’s HMO statute found in Chapter 641, Florida Statutes. 

63. Sections 641.513 and 641.3156 are statutorily incorporated into Defendant’s and 

Member’s policy. 

64. Section 641.3156(1) states that the state’s HMOs “must pay any hospital-service 

or referral-service claim for treatment for an eligible subscriber which was authorized by a provider 

empowered by contract with the [HMO] to authorize or direct the patient’s utilization of health 

care services and which was also authorized in accordance with the [HMO’s] current and 

communicated procedures...” (emphasis added). 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 17 of 31
65. If Member’s treatment was not emergent, then Member was referred to Plaintiff by 

Palmetto General Hospital to undergo medically necessary treatment. 

66. Palmetto General Hospital and its staff physicians are permitted to authorize and 

direct Member’s utilization of health care services as medical necessity dictates pursuant to the 

terms of their network agreement with Defendant. 

67. Defendant has wrongfully refused to pay Plaintiff the amount due for the submitted 

claims in violation of the statute. 

68. Florida Statute Section 641.513 establishes the proper reimbursement for 

emergency services rendered by non-participating providers, such as Plaintiff, who do not have a 

contract with an HMO. The statute states in pertinent part: 

(5) Reimbursement for services pursuant to this section by a provider who 

does not have a contract with the health maintenance organization shall be the 

lesser of: 

(a) The provider's charges; 

(b) The usual and customary provider charges for similar services 

in the community where the services were provided; or 

(c) The charge mutually agreed to by the health maintenance 

organization and the provider within 60 days of the submittal of

the claim. (Emphasis Added.) 

69. In the alternative, if Member’s treatment is considered nonemergent, payment of 

Plauintiff’s claim is governed by Florida Statute Section 641.3156(1), which provides:

(3) A health maintenance organization must pay any hospital-service 

or referral-service claim for treatment for an eligible subscriber 

which was authorized by a provider empowered by contract with 

the health maintenance organization to authorize or direct the 

patient’s utilization of health care services and which was also 

authorized in accordance with the health maintenance 

organization’s current and communicated procedures, unless the 

provider provided information to the health maintenance 

organization with the willful intention to misinform the health 

maintenance organization. (Emphasis Added). 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 18 of 31
70. Plaintiff timely and directly submitted to Defendant claims for payment for medical 

services provided to Member in the amount of $554.00 for medical services rendered by Plaintiff 

to Member during their hospitalization which began on 7/10/2018. Rather than paying Plaintiff’s 

charges, or in the alternative if Plaintiff’s charges are determined to exceed the usual and 

customary provider charges, the usual and customary charges Defendant would be required to pay, 

Defendant paid only $102.80 for the medical services provided, a sum far below the usual and 

customary provider charges for the community or geographic area. 

71. The parties did not mutually agree on a charge to be paid for this claim. Therefore, 

Defendant was obligated to pay either Plaintiff’s charges or the usual and customary provider 

charges in the community where the services were provided. 

72. The Defendant already determined that the medical services provided by Plaintiff

were covered, and distributed payment to Plaintiff pursuant to the Policy. Plaintiff is simply

seeking complete reimbursement for its provided services in the amount of the billed charges. 

73. As a result, Defendant is in breach of its Policy with Member to which Plaintiff is

a third-party beneficiary.

74. As a direct and proximate result of such breach of the Policy, to which Plaintiff is

an intended third-party beneficiary, Plaintiff has suffered damages in the amount of the unpaid 

balance for its billed charges which are within the usual and customary charges for the medical

service provided or, in the alternative, what is determined to be the usual and customary charges

for the medical services provided, together with interest and reasonable attorney fees pursuant to

§§ 641.28 and 641.3155(6), Florida Statutes. 

WHEREFORE, Plaintiff demands judgment against Defendant Cigna for the unpaid 

balance of its full billed charges, as same are within the usual and customary charges, or in the 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 19 of 31
alternative, if Plaintiff’s billed charges are determined to be in excess of the usual and customary

charges for the community or geographic area, Plaintiff demands judgment for the unpaid usual 

and customary charges for the community or geographic area for its emergency and nonemergency

charges for the medical services rendered, together with pre-judgment interest and its reasonable

attorney fees and costs pursuant to §§ 641.28 and 641.3155(6), Florida Statutes, and such other 

relief as the Court deems just and proper. 

COUNT III – Breach of Implied-in-Fact Contract 

75. Plaintiff realleges the General Allegations (paragraphs 1-40) as if fully set forth

herein.

76. At all times material, Plaintiff billed for emergent medical services provided to

Defendant’s Member at Palmetto General Hospital, located in Miami-Dade County, Florida. 

77. Plaintiff has properly and timely submitted claims for medical services provided to 

Member in the amount of $554.00 to Defendant for the services rendered to Member. Rather than

paying Plaintiff’s charges, Defendant paid only $102.80 for the medical services provided, a sum 

far below the usual and customary provider rates for the community or geographic area.

78. Despite demands, Defendant has refused and continues to refuse to pay the usual 

and customary charges, and instead paid well below the usual and customary charges. 

79. The emergency and/or nonemergency services provided by Plaintiff were

medically necessary in the care and treatment of Member and were performed with the Defendant’s

knowledge. The care rendered by Plaintiff at Palmetto General Hospital was either properly

authorized or required no such authorization for the specific medical services rendered. 

Authorization issued by the Defendant encompasses medically necessary ancillary services

ordered in the course of the treating physician’s treatment plan. 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 20 of 31
80. Thus, the Defendant retained the benefit that was conferred to its Member without 

issuing the proper payment for the benefit. 

81. Defendant was aware of its obligation to out-of-network providers such as the 

Plaintiff and was aware that Plaintiff provided professional emergency and/or nonemergency

medicine serves to its member, with the reasonable expectation and understanding that their

services would be reimbursed by the Defendant at rates that comply with Florida Statutes Section

641.513(5). 

82. Defendant knew that the Plaintiff had not agreed to accept discounted rates from

Defendant on out-of-network claims, nor had they agreed to be bound by Defendant’s

reimbursement policies or rate schedules. 

83. The circumstances indicate that it would be inequitable for the Defendant to be 

permitted to collect premiums from their members and subscribers in return for agreeing to

properly reimburse providers that render covered medical services without paying the value 

thereof to the provider. See S. Broward Hosp. Dist. v. ELAP Services, LLC, 20-CV-61007, 2020 

WL 7074645, at *7 (S.D. Fla. Dec. 3, 2020); See also Surgery Ctr. of Viera, LLC v. 

UnitedHealthcare, Inc., 465 F. Supp. 3d 1211 (M.D. Fla. 2020). 

84. All conditions precedent were met for the Defendant to perform its obligations 

pursuant to the implied contract.

85. As a result, the circumstances are such that the Defendant should, in all fairness, be 

required to pay the proper amount for the services provided by Plaintiff to Member.

86. Due to Defendant’sfailure to pay the usual and customary chargesfor these medical

services, Defendant has been unjustly enriched, and Plaintiff has suffered damages in the amount 

of the unpaid balance for its billed charges which are within the usual and customary charges for

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 21 of 31
the medical services provided or, in the alternative, what is determined to be the usual and

customary charges for the medical services provided, together with prejudgment interest and its

reasonable attorney fees pursuant to §§ 641.28 and 641.3155(6), Florida Statutes.

WHEREFORE, Plaintiff demands judgment against Defendant Cigna for the unpaid 

balance of its full billed charges, as same are within the usual and customary charges, or in the 

alternative, if Plaintiff’s billed charges are determined to be in excess of the usual and customary

charges for the community or geographic area, Plaintiff demands judgment for the unpaid usual 

and customary charges for the community or geographic area for its emergency and nonemergency

charges for the medical services rendered, together with pre-judgment interest and its reasonable

attorney fees and costs pursuant to §§ 641.28 and 641.3155(6), Florida Statutes, and such other 

relief as the Court deems just and proper. 

DEMAND FOR JURY TRIAL

Plaintiff demands a trial by jury of all issues triable as a matter of right to a jury.

Dated this 6th day of July 2022. 

Respectfully Submitted,

 By: /s/ Patrick Sullivan 

 Patrick R. Sullivan, Esq.

Florida Bar No. 114135 

Mark L. Rosen, Esq.

 Fla. Bar No.: 45675 

 George E. Dahdal, Esq.

 Fla. Bar No.: 1031644 

LUBELL | ROSEN

Attorneys for Plaintiff 

200 South Andrews Avenue, Suite 900 

Fort Lauderdale, Florida 33301 

Telephone: (954) 880-9500 

Facsimile: (954) 755-2993 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 22 of 31
E-Mail: prs@lubellrosen.com; 

mlr@lubellrosen.com; 

ged@lubellrosen.com 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 23 of 31
 

 

IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT IN AND FOR DADE COUNTY, FLORIDA

 

 

 

 

 

DIVISION CASE NUMBER

El CIVIL MEMO 0|: DISPOSITION 2022-025496-SP-23

[3 OTHER Section NcFNrtT— E D

PLAINTIFF(S) vs. DEFENDANT(S) CLOCK-IN

Palmetto E K G & Echo Readers Cigna Healthcare Of Fla Inc AUG 2 5| 2922

‘PA’ N25! C L E R K

PLAINTIFF ATTORNEY(S) DEFENDANT ATTORNEY(S) DATE OF HEARImICUlT & CWEEOURTS

Mark L Rosen No Known Name 08/24/2022 - Small Claims 1:30 PM Pre-Trial

Conference

MOTIONS CALENDAR DIRECTIONS

TYPE OF CASE CONTINUED:

MOTION NOTICE OF SERVICE PROCESS

COURT RUL'NG 0” MOT'ON: ENDING SERVICE [I PENDING SETTLEMENT

[:1 GRANTED |:| DENIED E] ESTIMATED {:1 SET CASE FOR TIME REQUIRED

WITHHELD I] MEDIATION [I NON JURY TRIAL

COMMENTS: 

El JURY TRIAL

El STIPULATED WAIVER FOR APPEARANCE AT PRE-TRlAL

El ORDER INVOKING RULES OF CIVIL PROCEDURE

 

 

 

 E] MOTION TO INVOKE THE RULES OF CIVIL PROCEDURE

DISPOSITIONS

El DEFAULT E] FINAL JUDGMENT El DEFAULT JUDGMENT I] SUMMARY JUDGMENT El AGREED JUDGMENT

El ORDER OF DISMISSAL AMOUNT OF JUDGMENT JUDGMENT FOR THE PLAINTIFF

E] WITHOUT PREJUDICE PRINCIPAL $ INTEREST $ El STIPULATION FOR PAYMENT AND

ORDER OF DISMISSAL

[:1 WITH PREJUDICE COURT COSTS $ ATTORNEY FEES $

 

E] VOLUNTARY DISMISSAL 

 

CONDITION OF DISPOSITION

E] EXECUTION OF JUDGMENT WITHHELD

 

[:1 ORDER WITHHOLDING JUDGMENT

 

El PLAINTIFF TO SUBMIT PROOF

PENDING PAYMENT BY DEFENDANT OF THE ABOVE JUDGMENT AT A RATE OF

$ PER ,COMMENCING

WEEKIMONTH DATE

SWORN TESTIMONY TAKEN IN COURT:

JUDGMENT OR ORDER TO BE PREPARED BY: El PLAINTIFF [:I DEFENDANT El COURT

E] DEFENDANT TO FILE ANSWER lN DAYS

E! A DEFAULT IS HEREBY ENTERED AGAINST

FOR FAILURE

 

TO APPEAR AT PRETRIAL AS REQUIRED BY LAW

By: 

DEPUTY CLERK

HARVEY RUVIN

CLERK OF COURTS JUDGE

 

 

COURT REPORTER

 

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 24 of 31
1. 

2. 

Attorneys are professionally obligated to diligently litigate the case so litigation can conclude 

as soon as it is reasonably and justly possible. See Florida Rule of General Practice and 

Judicial Administration 2.545. The specific pretrial deadlines and requirements set forth 

herein shall be strictly enforced by the Court. Non-compliance with any part of this Order 

may result in sanctions including, but not limited to, striking of pleadings, monetary 

sanctions, waiver and/or default. It is on the parties to promptly and timely schedule hearings 

on filed motions.

The deadlines contained in this Order cannot be waived or extended by stipulation of the 

parties and remain in effect unless the Court grants an enlargement. A motion seeking an 

enlargement of a particular deadline shall specify detailed reasons for the enlargement and 

the amount of time requested.

In the event parties are unable to coordinate any non-dispositive and non-evidentiary hearing, 

deposition, or motion within a reasonable period of time (not less than 72 hours) and after 3 

documented attempts, the moving party shall unilaterally set the issue for hearing pursuant to 

divisional instructions to occur no less than 14 days and no more than 45 days after the third 

attempt.

3. 

IN THE COUNTY COURT OF THE ELEVENTH JUDICIAL CIRCUIT IN AND 

FOR MIAMI-DADE COUNTY, FLORIDA

COUNTY CIVIL DIVISION

CASE NO.:

SECTION: 

Plaintiff(s),

vs.

Defendant(s)

______________________________________/

UNIFORM CASE MANAGEMENT ORDER SETTING PRETRIAL DEADLINES AND 

RELATED REQUIREMENTS (GENERAL PATHWAY - COUNTY CIVIL 

PROCEDURE CASES)

PLAINTIFF SHALL SERVE THIS ORDER UPON A DEFENDANT WITHIN 10 DAYS OF 

ANY FILING BY THAT DEFENDANT.

ALL PARTIES MUST READ CAREFULLY AS STRICT COMPLIANCE IS MANDATORY.

In compliance with the mandatory requirements of governing Administrative Orders regarding 

case management, the Court hereby ORDERS as follows:

2022-025496-SP-23 Palmetto E K G & Echo Readers (PA) ND01 Cigna Healthcare Of Fla Inc

Filing # 156459020 E-Filed 08/31/2022 01:43:13 AM Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 25 of 31
4. SETTLEMENT: Counsel shall immediately notify the Court in the event of settlement and

submit a Stipulation of Settlement and Order of Dismissal. Counsel shall also notify the

Court of any pending hearings that will be cancelled as a result of the settlement.

SERVICE: Plaintiffs shall serve their actions promptly by _____________________ and in

compliance with Florida Rule of Civil Procedure 1.070. Service issues shall be addressed

promptly and with diligence. No extensions pursuant to Florida Rule of Civil Procedure 1.070 

shall be granted without specific proof of diligent effort to effect service and a written

explanation of what efforts the Plaintiff intends to pursue to effect service successfully, with

proposed deadlines. No extension to serve a defendant beyond _____________________ 

shall be allowed.

5.

6. The following litigation deadlines are set:

a.

b.

c.

d.

e.

ADDITION OF ANY NEW PARTIES shall occur by _____________________.

FACT WITNESS LIST shall be filed by _____________________. The fact witnesses 

shall be in alphabetical order and contain the names and addresses of all non-expert 

witnesses. Only those witnesses listed shall be permitted to testify without leave of 

Court. All witness lists shall include a brief description of the substance and scope of 

the testimony to be elicited. Within 30 days of discovering previously unknown 

witnesses, either party may seek leave of Court to amend their submissions, 

disclosures, or discovery obligations.

EXHIBIT LIST shall be filed by _____________________. The Exhibit List shall 

disclose a list of all documentary and physical evidence intended to be used at trial. 

Each item shall be specifically described and listed by number and description. Generic

descriptions of exhibits are subject to being stricken. All listed exhibits shall have been

made available to opposing counsel for examination, initialing, and copying. Parties

shall timely amend their exhibit list.

EXPERT WITNESSES shall be disclosed by _____________________ with the names 

and addresses of all the expert witnesses to be called at trial and all information 

regarding expert testimony that is required by Rule 1.280(b)(5)(A). This includes 

disclosing the expert’s area of expertise and serving a copy of each expert’s reports or 

answers to expert interrogatories, if a report was prepared and/or expert interrogatories

propounded. Each party is limited to one expert per specialty. No other expert

testimony shall be permitted at trial.

FACT AND EXPERT DISCOVERY, including all inspections, depositions, and

examinations, shall be completed no later than _____________________. Written

discovery shall be served no later than _____________________. The parties shall 

timely coordinate the scheduling and setting of depositions for all witnesses and/or 

parties they intend to depose.

MOTIONS FOR SUMMARY JUDGMENT and DAUBERT MOTIONS shall be filed

by _____________________ and heard no later than _____________________.

f.

g. OBJECTIONS TO PLEADINGS AND ALL OTHER PRETRIAL MOTIONS, except

11-03-2022 01-01-2023 01-31-2023 05-02-2023 05-02-2023 07-01-2023 11-27-2023 10-24-2023 08-30-2023 11-27-2023

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 26 of 31
for motions in limine, shall be filed by _____________________ and heard no later 

than _____________________. Any motion not filed and heard prior to the expiration 

of this deadline may be deemed waived or denied absent extraordinary circumstances 

which could not have been prudently anticipated, or by order of the Court entered 

prior to the expiration of the applicable time limitation.

MEDIATION: Parties are hereby referred to mandatory mediation, which shall be 

completed no later than _____________________. The parties shall comply with 

Florida Rules Civil Procedure 1.700, 1.710, 1.720, 1.730, and 1.750 as to the conduct 

of mediation. Plaintiff's counsel is appointed lead counsel to facilitate, mutually 

coordinate and schedule the mediation conference. Costs of mediation shall be borne 

equally by both parties. Failure to mediate in good faith may result in the imposition of 

monetary sanctions.

h. 

7. TRIAL: The projected date of trial is _____________________. A firm trial date will be 

ordered by the Court when the case is at issue pursuant to Florida Rule of Civil Procedure 

1.440. The parties shall do all things reasonable and necessary to assure the availability of 

their witnesses for the entire trial period or to otherwise preserve their testimony for trial as

provided by the Florida Rules of Civil Procedure. Failure to do so will not be grounds for a

continuance.

JOINT PRETRIAL STIPULATION: A Joint Pretrial Stipulation shall be filed by all parties

(via counsel of record) no later than _____________________. All parties shall cooperate in 

good faith in preparation of the Joint Pretrial Stipulation. Unilateral pretrial stipulations will 

not be accepted. The single, unified submission shall contain the following information in

separately numbered paragraphs or sections:

8. 

 Stipulated Statement of Facts: A list of those facts that can be stipulated to and require 

no proof at the trial, together with a concise, impartial statement of the facts of the 

case.

a.

b.

c. 

d. 

Statements of Disputed Law & Fact: Those issues of law and fact that are to be tried.

Witness Lists: Parties shall attach the witness lists filed consistent with Paragraph 6b.

and 6d. of this Order, including all rebuttal or impeachment witnesses. If any party

objects to any witness, such objections shall be stated in the Stipulation, setting forth

the grounds with specificity. At trial, all parties shall be strictly limited to witnesses

properly and timely disclosed.

Exhibit Lists: Counsel shall initial each other party’s exhibit list and exhibits

consistent with Paragraph 6c. of this Order. If any party objects to the introduction of

any such exhibit, such objection shall be stated in the Stipulation, setting forth the

grounds with specificity. Parties shall attach the final, initialed exhibit lists with

objections. Only those exhibits listed and initialed may be offered in evidence.

Jury Instructions: If the trial is a jury trial, counsel shall identify and attach all agreed

upon standard instructions and all special instructions. Any disputed jury instructions

shall be attached and identified as to the party that proposed the instruction, along with

copies of supporting case law.

e. 

09-29-2023 11-27-2023 11-27-2023 12-27-2023 11-27-2023

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 27 of 31
__________________________________________

COUNTY COURT JUDGE

DONE AND ORDERED in Chambers, at Miami-Dade County, Florida, on this

___________________________.

f. Verdict Forms: If the trial is a jury trial, the proposed jury verdict forms shall be

attached and designated as agreed to or disputed.

Motions in Limine: Each party shall make any anticipated motion(s) in limine

indicating all stipulations/agreed items and any motion(s) in limine requiring a Court

ruling.

g. 

h.

i. 

Trial Estimate: Each party shall provide an estimate of the number of days for trial.

Daubert issues: All Daubert issues involving any requests for Daubert-related

evidence shall be in writing. Failure to do so shall constitute a waiver of any Daubertrelated evidence issue.

Other issues: The parties shall list any other issue that could potentially take up

unnecessary time during the trial to facilitate the resolution of those matters prior to the

trial date.

j.

30th day of August, 2022

2022-025496-SP-23 08-30-2022 11:51 PM

2022-025496-SP-23 08-30-2022 11:51 PM Myriam Lehr

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 28 of 31
Copies Furnished to: 

Electronically Served

Mark Lawrence Rosen, mlr@lubellrosen.com

Mark Lawrence Rosen, acaservice@lubellrosen.com

Mark Lawrence Rosen, intservice@lubellrosen.com

Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 29 of 31
Filing # 157846887 E-Filed 09/21/2022 11:33:46 AM Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 30 of 31
Case 1:22-cv-23355-JEM Document 1-1 Entered on FLSD Docket 10/14/2022 Page 31 of 31