Orthopedics Institute Sues Insurance Over Failure to Reimburse

On Monday a case was removed to the New Jersey District Court from the Superior Court of New Jersey Law Division; Monmouth County. The case was filed by Advanced Orthopedics Institute against Oxford Health Insurance, and concerns the alleged underpayment of medical bills due to the plaintiffs status as an out of network provider.

Advanced Orthopedics and Dr. Grigory Goldberg were the treating physicians on call when patient “K.G.” presented to the emergency room in extreme pain and unable to walk., the complaint said. After performing diagnostic procedures, it was discovered that the patient would need urgent spinal surgery. The plaintiffs allegedly obtained authorization from the defendant insurance company with the reasonable reliance that the authorized services would be paid at a reasonable rate.

The complaint said that after being billed over $269,859.50, the insurance company paid $4,671.36, less than 2% of the billed charges. In addition, the insurance company is said to have indicated that the patient would be responsible for the remaining charges, which the plaintiffs say is contrary to a New Jersey law which requires that patients be held harmless for any charges over cost sharing amounts such as deductibles, co-payments, and co-insurance.

The plaintiffs are suing for breach of implied contract, breach of warranty of good faith and fair dealing, promissory estoppel and unjust enrichment. The plaintiffs are represented by Buttaci Leardi & Werner and Cohen Howard LLP. The defendants are represented by Stradley Ronon Stevens & Young.