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Home My WebLink About01-1479COMI~c)NWEALTH OF PENNSYLVANIA COURT OF COMMON PLEAS JUDICIAL DISTRICT NOTICE OF APPEAL FROM DISTRICT JUSTICE JUDGMENT NOTICE OF APPEAL Notice is given that the appellant has filed in the above Court of Common Pleas an appeal from the judgment rendered by the District Justice o~ the date and in the case me~.~..md belo~. oq - I - zip COOE IN THE CASE O~ (/:'~n~) 1S~GNATURE O~ AP~ ~ ~ A~ A~NT / // . This' LT 19 J 100~¢k will ~ ~ ONLY --n this ,,G~. is ,quJ,d u~r P~ R~,~,. ~ ff 8~,, ,~ C~AIM~T (s, ~. ~.C.'.J.'. NO. ~_~tbe of A~I, .~ mcei~ by t~ Dis~ict Jus~ce, will eem~ as ~ 1001 (6)in acti~ ~t~ District J~tice, ~ MUST ~PERSEDEAS ~ t~ J~t ~ ~sses~ in this cas~ PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE (This section of form to be used ONLY when appel/ant was DEFENDANT (see Pa. R.C.P.J.P. No. 1001(7 ) in action before D/strict Justice. IF NOT USED, detach from copy of notice of appeal to be served upon appellee). C,,~ , PRAEClPE: To Prothonotary ~'~'~0'~ I~...~ ~U [Z.(~,(.(.~.~y ~ ~ ~_~ Enter rule upon ~' '"~ '--~-.~ · ''N,~qe' Ot'--L-'e~e~s)~F , appellee(s), to file a complaint in this appeal (Common Pleas No. ~) / ' //"/'~ ~../~.~ ) within twenty (20) clays after(~/;f~Lor~s~y of j~ment of non pros. KULe: T° "' ~ ~d~B ~I~BI~IL~ ~[~~ ' appellee(s)' // (1) You am notified that a rule is hereby entered upon you to file a comp/aint in this appeal within twenty (20) days aftra the date of service of this rule upon you by personol service or by certified or registered maiL (2) If you do not file a complaint within this time, a JUDGMENT OF NON PROS WILL BE ENTERED AGAINST YOU. (3) The date of service of this rule if service was by mail is the date of mailing. AOPC 312-84 COURT FILE TO BE FILED WITH PROTHONOTARY PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT (This proof of service MUST BE FILED WITHIN TEN (10) DA YS AFTER filing the notice of appeal. Check applicable boxe~) COMMONWEALTH OF PENNSYLVANIA COUNTY OF ; ss AFFIDAVIT: I hereby swear or affirm that I served ~ a copy of the Notice of Appeal, Common Pleas No. __ upon the District Justice designated therein on (date of service) -- , [] by personal service [] by (certified) (registered) mail, sender's receipt attached hereto, and upon the appellee, (name) on , 19__ [] by personal service [] by (certified) (registered) mail, sender's receipt attached hereto. [] and further that i served the Rule to File a Complaint accompanying the above Notice °f Appeal up°n the appellee(s) t° wh°m the Rule was addressed on , 19 -~ ~ by personal sec'vice ~ by (certified) (registered) mail, sender's receipt ~tttached hereto. SWORN (AFFIRMED) AND SUBSCRIBED BEFORE ME THIS ~_ DAY OF _ ,19. --. Signature of affiant Signature of official before whom affidavit was made Title of official My commission expires on COMMONWEALTH OF PENNSYLVANIA COUNTY OF: CUMBERLAND Mag. OisL NO,: 09-1-02 DJ Name: Hon. ROBERT V. MANLOVE ^~ .... 1901 STATE STREET CAMP HILL, PA (717) 761-0583 17011-0000 ROBERT V. MANLOVE 1901 STATE STREET CAMP HILL, PA 17011-0000 NOTICE OF JUDGMENT/TRANSCRIPT CIVIL CASE PLAINTIFF: NAME and ADDRESS ~GRANDVIEW SURGERY & LASER ~ 205 GRANDVIEWAVE CAMP HILL, PA 17011 VS. DEFENDANT: NAME and AOORESS ~ICKING, CAROLINE A ~ 6243 STANFORD CT MECHANICSBURG, PA 17055 Docket No.: CV- 0000466-00 Date Filed: 12/27/00 THIS IS TO NOTIFY YOU THAT: Judgment: [-~ Judgment was entered for: (Name) ~ Judgment was entered against: (Name) FOR PLAIN'PIFF ~RA~u'~VTRW RT'I'R~R~V ~ in the amount of $ on: (Date of Judgment) [~ Defendants are jointly and severally liable. ~ Damages will be assessed on: [~ This case dismissed without prejudice. ---]Amount of Judgment Subject to Attachment/Act 5 of 1996 $ [~ Levy is stayed for days or [~ generally stayed. [~ Objection to levy has been filed and hearing will be held: Date: Time: Place: (Date & Time) $ 3,173.20 $ 67.00 $ .00 $ .00 $ 3,240.20 Amount of Judgment Judgment Costs Interest on Judgment Attorney Fees Total Post Judgment Credits Post Judgment Costs ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS AFTER THE ENTRY OF JUDGMENT .lNG A NOTICE OF APPEAL WITH THE PROTHONOTARY/CLERK OF THE COURT OF COMMON PLEAS, CIVIL DIVISION. YOU ..E JUD / C T F/~M WITH Y .O,U R,NO'I~EOF APPEAL MUST INCLUDE A COPY OF T ~,__~_~ JUD(~¢/~IId~T .,~ ,.. '% ~. '", ~ 1:1;*~ tel,', ~ Date ~ .::' ,'.",,~'~VOi~trl~ Justice I certify that this is a true anG~pr'rCt"~py ::.. ~.,' ' Date / My commission expires first Monday of January. 2006 ",,,, SEAL ,,,,'" AOPC 315-99 Brigid Q. Alford, Esquire Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 315 N. Front Street PO Box 741 Harrisburg, PA 17108-0741 (717) 236-9377 Attorneys for Plaintiff GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF Ve CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA : NO. 01-1479 CIVIL : CIVIL ACTION - LAW NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are wamed that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 Liberty Ave. Carlisle, PA 17013 (800) 990-9108 NOTICIA Le han demandado a usted en la corte. Si usted quiere defenderse de estas demandas expuestas en las paginas siguientes, uted tiene viente (20) dias de plazo al partir de la fecha de le demanda y la notificacion. Usted debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus defensas os sus objeciones a leas demandas en contra de su persons. Sea avisado que si usted no se defiende, la corte tomara medidas y peude entrar una order contra usted sin pervio aviso o notificacion y por cualquier queja or alivio que es pedido en la peticion de demanda. Usted peude perder dinero os sus propiedades o ostros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABODAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PAGAR RAL SERVICIO, VAYA EN PERSONA O LLAME POR TELEFONE A LA ICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA VERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. CUMBERLAND COUNTY BAR ASSOCIATION 2 Liberty Ave. Carlisle, PA 17013 (800) 990-9108 Brigid Q. Alford, Esquire Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOI~ & WICKERSHAM 315 N. Front Street PO Box 741 Harrisburg, PA 17108-0741 (717) 236-9377 Attorneys for Plaintiff GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF Ve CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA : NO. 01-1479 CIVIL : CIVIL ACTION - LAW COMPLAINT Plaintiff, Grandview Surgery & Laser Center, by its attorneys, Brigid Q. Alford, Esquire, and Boswell, Tintner, Piccola & Wickersham, and presents its complaint against Defendant, Caroline A. Picking, as follows: 1. Plaintiff, Grandview Surgery & Laser Center, is a Pennsylvania corporation, with its principal place of business located at 205 Grandview Ave., Camp Hill, Cumberland County, Pennsylvania 17011. 2. Defendant, Caroline A. Picking, is an adult individual, currently residing at 6243 Stanford Court, Mechanicsburg, Cumberland County, Pennsylvania 17055. 3. On October 1, 1999, Defendant has surgery at Plaintiff's facility. 4. On October 1, 1999, prior to the commencement of the surgical procedure, Defendant completed a document entitled "Financial Agreement, Assignment of Benefits and Release of Record(s)." A copy of this document is attached hereto and identified as Exhibit "A". 5. Among the information provided to Plaintiffby Defendant on the face of the aforementioned Financial Agreement was a representation that Defendant had medical insurance coverage and that her insurer was Health Assurance. 6. The aforementioned Financial Agreement also stated, in part: I hereby agree, whether I am signing as patient or guarantor, to pay all the sums due the facility at the usual and customary charge the facility. I hereby waive all claims of exemption. Should the account be referred to an attorney or collection agency, I shall pay reasonable attorney's fees and collection expenses whether suit if filed or not. Delinquent accounts and amounts (those not paid within 60 days from the date of service) may bear interest on the unpaid amount to the maximum amount allowed by law. I understand that I am financially responsible for charges not paid within said 60 days and for charges not covered by this assignment. I understand that the facility files for reimbursement from my insurer or other payor as a courtesy, and failure on the part of the insurer to make payment shall not relieve me of my obligation to pay the facility. 7. Following the surgical procedure, Plaintiff filed for reimbursement from Defendant's insurance company, as per information given to it by Defendant. 8. Subsequently, Plaintiffwas informed by Health Assurance that Defendant's medical coverage was terminated on September 18, 1999, and that there were no benefits available to reimburse Plaintiff for services provided to Defendant on October 1, 1999. 9. On or about July 19, 2000, Plaintiffnotified Defendant of the response it had received from Health Assurance, and directed Defendant to pay the balance due. 10. Despite Plaintiffs numerous attempts to collect this amount, including engaging the services of an attorney, Defendant has continuously refused to make payment to Plaintiff for the balance due. 11. The current outstanding balance due is $3,240.20, which includes the unpaid medical bill of $2,440.92 and attorney's fees of $799.28, added as per the language of the aforementioned Financial Agreement.. WHEREFORE, Plaintiff demands judgxnent in an amount not in excess of $25,000.00, which amount requires submission of this matter to compulsory arbitration, plus interest and costs of suit. DATE: March ~r~ 2001 RESPECTFULLY SUBMITTED, BOSWELL, TINTNER, PICCOLA & WICKERSHAM Brigid Q. ~lford, Esquire/.,] Attorney for Plaintiff Grandview Surgery & Laser Center HEALTNSOUTH GRANDVlEW SURGERY AND LASER CEffi'ER 205 GranclviewAvanue, Camp Hill, Pennsylvania 17011 · 717 731-5444 Pa t icn ~ ID: 194-58-5629 PICKING. CAROLINE . 807 N WAJ_NUI SI, MBCitANICSBURG, PA 17055 . SELF ~ 19~-~8-5629 ~t ASSU~CE / ~I SBURG ~ ~X 205 194-58-5629-01 j 1014.11[:001 J 3350276 DE,IL.hi'H, ~D, WlLLIA.~i, W. - - MASS RIGHT INDEX FINGER EXCISIONAL BIOPSY OF RIGHT INDEX FINGER SOFT TISSUE ~IASS FINANCIAL AGREEMENT, ASSIGNMENT OF BENEFITS AND RELEASE OF RECORD(S) I hereby assign to and authorize payment directly to the facility named above (the "facility") of all benefits due me under Medicare, Medicaid, or any insurance policy providing ben- efits for facility charges, for services rendered by the facility. A photostatic copy of this agreement shall be considered effective and valid as the original, I irrevec bly agre. e that the fac fy may disclose, to the extent allowed by law m medical and fin ' ' ...... Corpora~n and ,ts employees and agents including entities under contrac* '"'*hY~ ............. _a.n._c[,.,a~l.r~? to.!.a) a.,ny afl[hate o.f.the fac,hty, speclf,cally including HEALTHSOUTH :ontractlor by law to the facility or to me 'or an,, "~rson *r .............. ~,_..~,_,,. o_.,;,:~_ .~ ~,.~.u.~ qua[, ~.y ,a.n~. or ummnon..r, eview; {gl any person or entity which may be able under · ~ , ~ ~ u ~.,,,y ,~.puu~u,u ,or a, or part orTne TaClII~ S cnargss, speclTically including any insurance company or their agents or employees; (c) any person or entity to whom I have been referred by the facility or by my physician for continued care; (d) any physician treating, consulting or otherwise performing ;;~ces for me, including his or her employees and agents; (el the Health Care Financing Administration, any other governmental or accrediting agency, or their agents or eml~cy- All facility charges are due and owing at discharge. In consideration of the services to be rendered, to the extent not expressly prohibited by law or by the contract between the facil- i fy and my third pan',/payor. I HEREBY AGREE, WHETHER I AM SIGNING AS PATIENT OR GUARANTOR, TO PAY ALL SUMS DUE THE FAClLi'D' AT THE USUAL AND CUSTOMARY CHARGE OF THE FAClLI~. I hereby waive all claims of exemption. Should the account be referred to an attorney or collection agency for collection, I shall pay reasonable attorney's fees and collection expenses whether suit is filed or not. Delinquent accounts and amounts (those not paid within 60 days from the date of service) may bear interest on the unpaid amount up to the maximum amount allowed by law. I understand that I am financially responsible for charges not paid within said 60 days and for charges not covered by this assignment. I understand that the facility files for reimbursement from my insurer or other payor as a courtesy, and failure on the part of the insurer to make payment shall not relieve me of my obligation to pay the facility. I certify that I am the patient or that I am finaosJally responsible for the services rendered and do hereby unconditionally guaranty the payment of all amounts when and as due, Zacilify employees are NOT able to define your insurance coverage. If you have coverage questions, you are advised to call your insurance carrier GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFEND ~.NT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA .. : NO. 01-1479 CIVIL : CIVIL ACTION - LAW I, Doris West, on foregoing Complaim are understand that false state to unswom falsification tc DATE: VERIFICATION ,ehalf of Plaintiff, hereby verify that the facts contained in the me and correct to the best of my knowledge, information and belief. I ments herein are subject to the penalties of 18 Pa.C.S.A. §4904 relating authorities. DORIS WEST GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA _. : NO. 01-1479 CIVIL : : CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, Denise L. Foster, Paralegal, do hereby certify that I have served a true and correct copy of the Complaint on the following: Method of Service: cirSt class mail ertified mail Other Caroline A. Picking 6243 Stanford Court Mechancisburg, PA 17055 DATE: March 27, 2001 BOSWELL, TINTNER, PICCOLA & WICKERSHAM ~D~enise L. Foster, Paralegal Brigid Q. Alford, Esquire Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 315 N. Front Street PO Box 741 Harrisburg, PA 17108-0741 (717) 236-9377 Attorneys for Plaintiff GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA : NO. 01-1479 CIVIL : CIVIL ACTION - LAW COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN AFFIDAVIT OF SERVICE :SS. . Denise L. Foster, Paralegal, being duly sworn according to law, deposes and says that I am a competent adult, and I served a tree and correct copy of the Complaint on the Defendant, Caroline A. Picking, certified mail, return receipt requested on March 27, 2001. The Defendant received the complaint on March 28, 2001, as evidenced by the green card attached hereto. ~O f_~/'~ Denise L. Foster, Paralegal Sworn to and subscribed before Notary Public Notarial Seal Pamela A. Mobius, Notary Public Harrisburg Dauphin Co~nty My Comrn ssion Expires Feb. 10, 2003 GRANDVIEW SURGICAL & : LASER CENTER, : Plaintiffs : V. : : CAROLINE A. PICKING : Defendant : V, ' HEALTH ASSURANCE, : Additional Defendant: IN THE COURT OF COMMON PLEAS OF OF CUMBERLAND COUNTY, PENNSYLVANIA No.: 01-1479-CIVIL CIVIL ACTION - LAW ENTRY OF APPEARANCE Please enter our appearance on behalf Defendant, Caroline A. Picking, only in the above captioned. Respectfully submitted, McKissock & Hoffman, P.C. B. Craig Black Attorney I.D. No. 36818 Edwin A.D. Schwartz Attorney I.D. No. 75902 105 North Front Street Suite 205 Harrisburg, PA 17101 (717 ) 234-0103 CERTIFICATE OF SERVICE I hereby certify that I am this day serving a copy of the foregoing Entry Of Appearance upon the person(s) and in the manner indicated below, which service satisfies the requirements of the Pennsylvania Rules of Civil Procedure, by depositing a copy of same in the United States Mail, first-class postage prepaid, addressed as follows: Brigid Alford, Esquire Boswell, Titner, Picolla & Wickersham 315 North Front Street Harrisburg, PA 17108-0741 Counsel for Plaintiffs McKissock & Hoffman, P.C. B. Craig Black, Esc Supreme Court I.D. No. 36818 Edwin A.D, Schwartz, Esquire Supreme Court I.D. No. 75902 105 North Front Street Suite 205 Harrisburg, PA 17101 Telephone: (717) 234-0103 Attomeys for Defendant, Caroline A. Picking GRANDVIEW SURGICAL & LASER CENTER, Plaintiffs V. CAROLINE A. PICKING Defendant V. HEALTHASSURANCE, INC., Additional Defendant IN THE COURT OF COMMON PLEAS OF OF CUMBERLAND COUNTY, PENNSYLVANIA No.: 01-1479 - CIVIL · CIVIL ACTION - LAW 3. 4. 5. 6. which is appended to PI~ no responsive pleading 7. Admitted. Admitted. Admitted. Admitted. Admitted. The averments in paragraph 6 characterize portions of a written document intiffs Complaint. The document therefore speaks for itself and is required. and information to form a belief as to the truth of the averments set forth in paragraph 1 of Plaintiffs Complaint. Strict proof, if relevant is demanded upon the trial of the matter. 1. Denied· After reasonable investigation Defendant is of insufficient knowledge AND NOW, comes Defendant, Caroline A. Picking, by and through her attorneys, McKissock & Hoffman, P·C., and files the following Answer and New Matter to Plaintiffs Complaint: ANSWER AND NEW MATTER OF DEFENDANT CAROLINE A. PICKING TO DEFENDANT'S COMPLAINT 8. Admitted. 9. Admitted. 10. Denied as stated. For the reasons more fully set forth in Defendant's Joinder Complaint against Additional Defendant HealthAssurance, Inc., it is denied that Defendant is obligated, legally or otherwise to make payment to Plaintiff for the balance due. Defendant hereby incorporates by reference each and every averment in Defendant's Joinder Complaint against Additional Defendant. 11. Denied. Defendant hereby incorporates the averments set forth in paragraph 10 of the foregoing Answer. Moreover it is denied that the sum of Seven Hundred and Ninety-Nine Dollars and Twenty-Eight Cents ($799.28) represents a reasonable amount of attorneys fees for.Plaintiff's efforts in the within matter. WHEREFORE, Defendant respectfully requests that this Honorable Court enter judgment in her favor and to dismiss Plaintiff's Complaint with prejudice. Paragraphs 1 through 11 of the forgoing Answer are incorporated herein by reference. 13. Defendant hereby incorporates by reference Defendant's Joinder Complaint against Additional Defendant, a copy of which is attached hereto, labelled as Exhibit "A" and specifically incorporated herein by reference. Respectfully submitted, McKissock & Hoffman, P.C. Attorney I.D. #36818 Edwin A.D. Schwartz Attorney I.D. #75902 105 North Front Street Suite 205 Harrisburg, PA 17101 (717) 234-0103 I, Caroline A. Picking, hereby vedfies that the statements made in the foregoing Answer And New Matter To Defendant's Complaint, are true and correct to the best of my knowledge, information and belief, and makes these statements subject to the penalties of 18 Pa. C.S. Section 4904 relating to unswom falsification to authorities. DATE: /`3/ ' 1-7~ ,2001 Brigid Q. Alford, Esquire Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 315 N. Front Street PO Box 741 Hamsburg, PA 17108-074.1 (717) 236-9377 Attorneys ~br Plaintiff GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF Vo CAROLINE A. PICKING, DEFENDANT NO. 01-1479 CIVIL CIVIL ACTION - LAW IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYLVANIA NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims-' set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are ~varned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION ? Liberty Ave. Carlisle, PA 17013 (800) 990-9108 ,mu th~ seea. I 0t said Couaat Carlls~e Pa NOTICIA Prothonotary' ' Le han demandado a usted en la corte. Si usted quiere defenderse de estas :. demandas expuestas en las paginas siguientes, uted tiene viente (20) dias de plazo al partir de la fecha de le demanda y la notificacion. Usted debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus defensas os sus objeciones a leas demandas en contra de su persons. Sea avisado que si usted no se defiende, la corte tomara medidas y peude entrar una order contra usted sin pervio aviso o notificacion y por cualquier queja or alivio que es pedido en la peticion de demanda. Usted peude perder dinero os sus propiedades o ostros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABODAGO IMMEDIATPdViENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PAGAR RAL SERVICIO, VAYA EN PERSONA O LLAME POR TELEFONE A LA ICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA VERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. CUMBERLAND COU2N'TY BAR ASSOCIATION 2 Liberty Ave. Carlisle, PA 17013 (800) 990-9108 Brigid Q. Alford, Esquire Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 315 N. Front Street PO Box 741 Bamsburg, PA 17108-0741 (71,7) 236-9377 Attorneys for Plaintiff GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA ._ : : NO. 01-1479 CIVIL : : CIVIL ACTION - LAW COMPLAINT Plaintiff, Grandview Surgery & Laser Center, by its attorneys, Brigid Q. Alford, Esquire, and Boswell, Tintner, Piccola & Wickersham, and presents its complaint against Defendant, Caroline A. Picking, as follows: 1. Plaintiff, Grandview Surgery & Laser Center, is a Pennsylvania corporation, with its principal place of business located at 205 Grandview Ave., Camp Hill, Cumberland County, Pennsylvania 17011. 2. Defendant, Caroline A. Picking, is an adult individual, currently residing at 6243 Stanford Court, Mechanicsburg, Cumberland County, Pennsylvania 17055. 3. On October 1, 1999, Defendant has surgery at Plaintiff's facility. 4. On October 1, 1999, prior to the commencement of the surgical procedure, Defendant completed a document entitled "Financial A~eement, Assignment of Benefits and Release of Record(s)." A copy of this document is attached hereto and identified as Exhibit "A". 5. Among the information provided to Plaintiffby Defendant on the face of the aforementioned Financial Agreement was a representation that Defendant had medical insurance coverage and that her insurer was Health Assurance. The aforementioned Financial Aga'eement also stated, in part: I hereby agree, whether I am signing as patient or guarantor, to pay all the sums due the facility at the usual and customary charge the facility. I hereby waive all claims of exemption. Should the account be referred to an attorney or collection agency, I shall pay reasonable attorney's fees and collection expenses whether suit if filed or not. Delinquent accounts and amounts (those not paid within 60 days from the date of service) may bear interest on the unpaid amount to the maximum amount allowed by law. I understand that I am financially responsible for charges not paid within said 60 days and for charges not covered by this assignment. I understand that the facility files for reimbursement from my insurer or other payor as a courtesy, and failure on the part of the insurer to make payment shall not relieve me of my obligation to pay the facility. Following the surgical procedure, Plaintiff filed for reimbursement from Defendant's insurance company, as per information given to it by Defendant. 8. Subsequently, Plaintiff was informed by Health Assurance that Defendant's medical coverage was terminated on September 18, 1999, and that there were no benefits available to reimburse Plaintiff for services provided to Defendant on October 1, 1999. 9. On or about July 19, 2000, Plaintiff notified Defendant of the response it had received from Health Assurance, and directed Defendant to pay the balance due. 10. Despite Plaintiff's numerous attempts to collect this amount, including engaging the services of an attorney, Defendant has continuously refused to make payment to Plaintiff for the balance due. 11. The current outstanding balance due is $3,240.20, which includes the unpaid medical bill of $2,440.92 and attorney's fees of $799.28, added as per the language of the aforementioned Financial Agreement.. WHEREFORE, Plaintiffdemands judgment in an amount not in excess of $25,000.00, which amount requires submission of this matter to compulsory arbitration, plus interest and costs of suit. DATE: March 27 2001 RESPECTFULLY SUBIVlITTED, BOSWELL, TINTNER, PICCOLA & WICKERSHAM BY: Esquire/./ Attorney for Plaintiff Grandview Surgery & Laser Center HEALTHSOUTH GRANDVlEW SURGERY AND LASER CENTER 205 Grandview Avenue · Camp Hill, Pennsylvania 17011 · 717 731.5444 Rcf: 19 i- ~/'ATE 194-58- 5629 P1CKING, C.~ROLiNE . 807 N W.~J.~NL-~ ST, I~LAT1ON TO RESPONSIBLE PARTY I RE~::)NSIBUE pARTY ~N S£1.F I 19.t-5S-5620 WORK ~E 7] '/.' I.D. .I~/8~N I OFIOUPt I INSURED'S EMP1.OYER A~IO PHONE I Dr:'~ILTFH, .MD, WILLIAM, \V. MASS }~l(;l.17 ~..I.)LX FIXEE'R ~ ~(I.INE 1 ) EXCISIONAL BIOPSY OF IUC3HT INDEX FINGER SOFT TISSUE .MASS FINANCIAL AGREEMENT, ASSIGNMENT OF BENEFITS AND RELEASE OF RECORD(S) hereby assign to and authorize payment directly to the facility named above (the "facility") of all benefits due me under Medicare, Medicaid, or any insurance policy providing ben- ~.fits for facility charges, for services rendered by the facility. A photostatic copy of this agreement shall be considered effective and valid as the original. I irrevoc]b v agree that the fac ty may disclose to the ex'tent allowed by aw, my medica and f nancial record to (a) any affiliate of the facility, specifically including HEALTHSOUTH :orporak~cor~ and its emp cyees and agents, nduding ent t es under contract with same to prOVof_thede quality andJOrcharges,UfilizatiOnspecificallyreVieW;includingb) any perSOnany insurance°r entitycompanyWhich mayor betheirliableagentsUnder :ontractJor by law to the facility or to me, or any person or entity responsible for a or part facility's or ~ ~mployees; (c) any person or entity to whom I have been referred by the facilit~ or by my physician for continued care' (d) any phys c an treating, consulting or otherwise pedorming ~ervices for me, including his or her employees and agents; (e) the Health Care Financing Administration, any other governmental or accrediting agency, or their agents or employ- ~es. All facility charges are due and owing at discharge. In consideration of the services to be rendered, to the extent not expressly prohibited by law or by the contract between the facil- ty and my third party payor. I HEREBY AGREE, WHETHER I AM SIGNING AS PATIENT OR GUARANTOR, TO PAY ALL SUMS DUE THE FACILITY AT THE USUAL AND CUSTOMARY CHARGE OF THE FACILITY. I hereby waive ail claims of exemption. Should the account be referred to an attorney or collection agency for collection, I shall pay reasonable attorney's fees and :ollection expenses whether suit is filed or not. Delinquent accounts and amounts (those not paid within 60 days from the date of service) may bear interest on the unpaid amount up to the maximum amount allowed by law. I understand that I am financially responsible for charges not paid within said 60 days and for charges not covered by this assignment. ~ understand that the facility files for reimbursement from my insurer or other payor as a courtesy, and failure on the part of the insurer to make payment shall not relieve me of my obligation to pay the facility. ~ certify that I am the patient or that I am financially responsible for the services rendered and do hereby unconditionally guaranty the payment of all amounts when and as due. =acility employees are NOT able to define your insurance coverage. If you have coverage questions, you are advised to call your insurance carrier. .-'~2 .-"/ ~ ' ." / 3AUT, I. of~ DO ,N/0T SIGN ~'S AC_~qEEMENh'-UNLESS YOU UNDERSTAND ITS CONTENTS. .~,///~/.~C~,/ ~ IFAIIENT , · ~, ~-~' t , "' DATE GUARANTOR ~ DATE .¥1TN-ES$ ..... "~ DATE GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF Vo CAROLINE A. PICKING, DEFENDANT IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYLVANIA NO. 01-1479 CIVIL CIVIL ACTION - LAW VERIFICATION I, Doris West, on behalf of Plaintiff, hereby verify that the facts contained in the foregoing Complaint are true and correct to the best of my -knowledge, information and belief. I understand that false statements herein are subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsxvom falsification to authorities. DORIS WEST DATE: GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFENDANT IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYL; A; IA NO. 01-1479 CIVIL CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, Denise L. Foster, Paralegal, do hereby certify that I have served a true and correct copy of the Complaint on the following: Method of Service: /First class mail Certified mail Other Caroline A. Picking 6243 Stanford Court Mechancisburg, PA 17055 BOSWELL, TINTNER, PICCOLA & WICKERSHAM DATE: March 27, 2001 CERTIFICATE OF SERVICE I hereby certify that I am this day serving a copy of the foregoing Answer And New Matter of Defendant Caroline A. Picking to Defendant's Complaint, upon the person(s) and in the manner indicated below, which service satisfies the requirements of the Pennsylvania Rules of Civil Procedure, by depositing a copy of same in the United States Mail, first-class postage prepaid, addressed as follows: Brigid Q. Alford, Esquire Boswell, Titner, Picolla & Wickersham 315 North Front Street Harrisburg, PA 17108-0741 Counsel for Plaintiffs HealthAssurance, Inc. 2575 Interstate Drive Harrisburg, PA 17110 McKissock & Hoffman, P.C. Supreme Court LD.--N-~.. 36818 Edwin A.D. Schwartz, Esquire Supreme Court I.D. No. 75902 105 North Front Street Suite 205 Harrisburg, PA 17101 Telephone: (717) 234-0103 Attorneys for Defendant, Caroline A. Picking GRANDVIEW SURGICAL & : LASER CENTER, : Plaintiffs : V, : : : : CAROLINE PICKING Defendant V, HEALTHASSURANCE, INC., : Additional Defendant : IN THE COURT OF COMMON PLEAS OF OF CUMBERLAND COUNTY, PENNSYLVANIA No.: 01-1479 - CIVIL CIVIL ACTION - LAW NOTICE TO DEFEND TO: HealthAssurance, Inc., Additional Defendant 2575 Interstate Drive Harrisburg, PA 17110 You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a wdtten appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are wamed that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the Complaint, or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17033 (800) 990-9108 JOINDER COMPLAINT OF DEFENDANT CAROLINE A. PICKING AGAINST ADDITIONAL DEFENDANT HEALTHASSURANCE; INC. 1. Defendant, Caroline ^. Picking, is an adult individual who currently resides at 6243 Stanford Court, Mechanicsburg, Cumberland County, Pennsylvania, 17055. 2. Additional Defendant, HealthAssurance, Inc., is a corporation operating in the Commonwealth of Pennsylvania with a registered business address of 2575 Interstate Drive, Harrisburg, Pennsylvania 17110. 3. Plaintiff instituted this action against Defendant alleging that Defendant failed to pay for services rendered to Defendant by Plaintiff in connection with surgery which was performed upon Defendant on October 1, 1999. A true and correct copy of Plaintiff's Complaint is attached hereto as Exhibit "A". 4. According to Plaintiff's Complaint, Defendant had surgery at Grandview Surgery & Laser Center on October 1, 1999. Paragraph 3 of Plaintiff's Complaint, Exhibit 5. In Plaintiff's Complaint, Plaintiff alleges that Plaintiff filed for reimbursement from Additional Defendant, HealthAssurance, Inc., for the services provided to Defendant in accordance with infermation provided by Defendant. (See: paragraph 7 of Plaintiff's Complaint, Exhibit "A"i.) According to Plaintiff's Complaint, Plaintiff was informed by Additional Defendant, Health^ssurance Inc., that Defendant's medical coverage was terminated on September 18, 1999 and that no benefits were available to reimburse Plaintiff for services ret dered to Defendant on October 1, 1999 (See: Plaintiff's Complaint Plaintiff for services rendered to Defendant on October 1, 1999 (See: Plaintiff's Complaint at paragraph 8, Exhibit "A"). 6. Defendant denies that medical insurance coverage provided to her by Additional Defendant was terminated on or about September 18, 1999 and that therefore no benefits would be available to reimburse Plaintiff for services provided to Defendant on October 1, 1999. 7. Defendant, Caroline A. Picking was an insured under a policy of health insurance issued between Additional Defendant and the Hecht Company. Defendant is not in possession of a copy of said policy, but avers, based upon information and belief, that Additional Defendant HealthAssurance, Inc., is in fact in possession and retains a copy of said policy. 8. Upon information and belief Defendant asserts that participant's identification number under the HealthAssurance policy is 194585629'01. 9. On or about September 15, 1999 Defendant met with her physician and surgeon for a consultation regarding surgical biopsy of a mass on the left index finger of Defendant's hand. 10. At the time of the consultation Defendant's physician recommended that a surgical biopsy of the mass be performed. 11. Prior to leaving the surgeon's office, Defendant and a representative of Defendant's surgeon whose name is currently unknown to Defendant, specifically inquired of Additional Defendant as to whether or not Defendant remained an insured under the 3 policy of insurance described above and sought per-certification and pre-approval for the performance of the surgery in order to insure that same would be covered for financial reimbursement under the terms of the HealthAssurance policy. 12. Additional Defendant represented and warranted to Defendant that Defendant was a covered insured under the policy and that financial re-numeration would be provided to the surgeon and facility where the surgery was to be performed. 13. In response to this inquiry Additional Defendant provided Defendant with the following authorization number confirming pre-certification and approval for reimbursement for said surgeries - Authorization #3350276. 14. Additional Defendant's confirmation of Defendant's coverage under the terms of the HealthAssurance policy and representation via authorization for the surgery and representations regarding reimbursement therefore was a material representation upon which Defendant relied in undergoing the procedure on October 1, 1999. 15. Pursuant to the authorization number, Plaintiff at the direction and upon approval of Defendant, submitted its charges to HealthAssurance which denied reimbursement for the charges contending that Defendant was ineligible for coverage on the date of service. A true and correct copy of an explanation of benefits form received by Defendant is attached hereto, labeled a Exhibit "B" and specifically incorporated herein by reference. Caroline A. Pickin_. v. HealthAssurance Fraud and MisreDresentation 16. Additional Defendant HealthAssurance, Inc., fraudulently misrepresented to Defendant that professional services and fees associated with the surgery which Defendant underwent on October 1, 1999 would be covered under its policy of insurance and that reimbursement for said professional services and equipment would be reimbursed in accordance with the terms of said policy. Said representation was made orally by Additional Defendant and is documented via Additional Defendant's issuance of an authorization number to Defendant for pre-certification of the procedure. 17. Additional Defendant knew or should have known that Defendant would reasonably rely upon said authorization and representations in ultimately determining to undergo the procedure. 18. Said representations by Additional Defendant was material to Defendant's decision to undergo said procedure and to incur the financial obligations therefore which, Defendant understood would be reimbursed by Additional Defendant pursuant to the terms of the policy. As a result of the foregoing conduct, Defendant has been required to respond to Plaintiff's claim, including Plaintiff's claim for counsel fees and costs in an amount of Three Thousand Two Hundred and Forty Dollars and Twenty Cents ($3, 240.20), for which Defendant makes demand upon Additional Defendant. WHEREFORE, Defendant Caroline A. Picking respectfully requests that this Honorable Court enter judgment in her favor and against Additional Defendant in an 5 amount of $3,240.20 together with such other relief as this Honorable Court deems appropriate and just, COUNT II Breach of Contract 19. The averments set forth in paragraphs 1 though 18 of the foregoing Complaint are incorporated by reference herein. 20. By virtue of Additional Defendant's issuance of a pre-certification number and pre-authorization number, Additional Defendant warranted and guaranteed that it would pay for services rendered to Defendant by Plaintiff. 21. By failing to honor Plaintiff's claim for reimbursement of services rendered to Defendant, Additional Defendant breached the express and implied contract and warranty which it entered with Defendant. 22. Defendant has made demand upon Additional Defendant to reimburse Plaintiff for services rendered to Defendant in accordance with the terms of the policy, which demand Additional Defendant has refused. 23. Defendant has satisfied all conditions precedent to filing and proceeding with this claim. WHEREFORE, Defendant respectfully requests that this Honorable Court enter judgment in Defendant's favor and against Additional Defendant in amount of $3,240.20 together with such other further relief as this Honorable Court deems just. 6 Unfair Trade Practice and Consumer Protection Law Claim 24. Paragraphs 1 through 23 of the foregoing Complaint are incorporated herein by reference. 25. Additional Defendant's issuance of a authorization number for Defendant to undergo services provided by Plaintiff constituted a representation and agreement that Additional Defendant would reimburse Plaintiff for the professional services rendered to Defendant is accordance with Additional Defendant's contract with Defendant. 26. Additional Defendant thereafter failed to comply with its agreement and refused to reimburse Plaintiff for services rendered to Defendant despite its representation to the contrary. 27. Additional Defendant's actions constitute a unfair and deceptive act or practice within the meaning of the Unfair Trade Practices and Consumer Protection Law (73 P.S. §201-1 et seq.). 28. In particular, Defendant's action constitutes an unfair and deceptive act or practice in that it: "(2) caus(es) the likelihood of confusion or of misunderstanding as to the source, sponsorship, approval or certification of goods or services;" (73 P.S. §201-2 (2). 29. Additional Defendant's actions as stated hereinabove are an unlawful act thereby authorizing Defendant to bring a private cause of action for the recovery of damages sustained by virtue of said deceptive practice. (73 P.S. §201-9.2). 30. Pursuant to the provisions of the Unfair Trade Practice and Consumer Protection Law, Defendant makes a claim for treble damages. (73 P.S. §201-9.2). WHEREFORE, Defendant respectfully prays your Honorable Court to enter an award in Defendant's favor and against Additional Defendant in the amount of Nine Thousand Seven Hundred and Twenty Dollars and Sixty Cents ($9,720.60) together with reimbursement of counsel fees and costs and such other relief as this Honorable Court deems appropriate. Respectfully submitted, McKissock & Hoffman, P.C. Attorney I.D. #36818 Edwin A.D. Schwartz Attorney I.D. #75902 105 North Front Street Suite 205 Harrisburg, PA 17101 (717) 234-0103 I, Caroline A. Picking, hereby verifies that the statements made in the foregoing Complaint Against Additional Defendant HealthAssurance, Inc., are true and correct to the best of my knowledge, information and belief, and makes these statements subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Caroline A. pi~~~ n DATE: /-.J( · ['7- ,2001 Brigid Q. Alford, Esquire Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 31 $ N. Front Street PO Box 741 Hamsburg, PA 1 ? 105-0741 (717) 236-9377 Attorneys for Plaintiff GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF Vo CAROLINE A. PICKING, DEFENDANT IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYLVANIA NO. 01-1479 CIVIL CIVIL ACTION - LAW - · NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims ' set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judg-ment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 Liberty Ave. Carlisle, PA 17013 (800) 990-9108 NOTIC~ . .9~a~ Le han demandado a usted en la cone. Si usted quiere defenderse de estas demandas expuestas en las paginas siguientes, uted tiene viente (20) dias de plazo al partir de la fecha de le demanda y la notificacion. Usted debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus defensas os sus objeciones a leas demandas en contra de su persons. Sea avisado que si usted no se defiende, la corte tomara medidas y peude entrar una order contra usted sin pervio aviso o notificacion y por cualquier queja or alivio que es pedido en la peticion de demanda. Usted peude perder dinero os sus propiedades o ostros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABODAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PAGAR RAL SERVICIO, VAYA EN PERSONA O LLA:ME POR TELEFONE A LA ICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA VERIGUAR DONDE SE PUEDE CONSEGULR ASISTENCIA LEGAL. CUMBERLAND COUNTY BAR ASSOCIATION 2 Liberty Ave. Carlisle, PA 17013 (800) 990-9108 Brigid Q. Alford, Esquire Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 315 N. Front Street PO Box 741 Harrisburg, PA 17108-07~.1 (717) 236-9377 Attorneys for Plaintiff GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA : : NO. 01-1479 CIVIL : : CIVIL ACTION - LAW COMPLAINT Plaintiff, Grandview Surgery & Laser Center, by its attorneys, Brigid Q. Alford, Esquire, and Boswell, Tintner, Piccola & Wickersham, and presents its complaint against Defendant, Caroline A. Picking, as follows: t. Plaintiff, Grandview Surgery & Laser Center, is a Pennsylvania corporation, with its principal place of business located at 205 Grandview Ave., Camp Hill, Cumberland County, Pennsylvania 1701 l. 2. Defendant, Caroline A. Picking, is an adult individual, currently residing at 6243 Stanford Court, Mechanicsburg, Cumberland County, Pennsylvania 17055. 3. On October I, 1999, Defendant has surgery at PlaintiWs facility. 4. On October 1, 1999, prior to the commencement of the surgical procedure, Defendant completed a document entitled "Financial Agreement, Assignment of Benefits and Release of Record(s)." A copy of this document is attached hereto and identified as Exhibit "A". 5. Among the information provided to Plaintiffby Defendant on the face of the aforementioned Financial Agreement was a representation that Defendant had medical insurance coverage and that her insurer was Health Assurance. 6. The aforementioned Financial Agreement also stated, in part: I hereby agree, whether I am signing as patient or guarantor, to pay all the sums due the facility at the usual and customary charge the facility. I hereby waive all claims of exemption. Should the account be referred to an attorney or collection agency, I shall pay reasonable attorney's fees and collection expenses whether suit if filed or not. Delinquent accounts and amounts (those not paid within 60 days from the date of service) may bear interest on the unpaid amount to the maximum amount allowed by law. I understand that I am financially responsible for charges not paid xvithin said 60 days and for charges not covered by this assignment. I understand that the facility files for reimbursement from my insurer or other payor as a courtesy, and failure on the part of the insurer to make payment shall not relieve me of my obligation to pay the facility. 7. Following the surgical procedure, Plaintiff filed for reimbursement from Defendant's insurance company, as per information given to it by Defendant. 8. Subsequently, Plaintiff was informed by Health Assurance that Defendant's medical coverage was terminated on September 18, 1999, and that there were no benefits available to reimburse Plaintiff for services provided to Defendant on October 1, 1999. 9. On or about July 19, 2000, Plaintiff notified Defendant of the response it had received from Health Assurance, and directed Defendant to pay the balance due. 10. Despite PlaintifPs numerous attempts to collect this amount, including engaging the ser','ices of an attorney, Defendant has continuously refused to make payment to Plaintiff for the balance due. 11. The current outstanding balance due is $3,240.20, which includes the unpaid medical bill of $2,440.92 and attorney's fees of $799.28, added as per the language of the aforementioned Financial Ag-reement.. WHEREFORE, Plaintiff demands judgment in an amount not in excess of $25,000.00, which amount requires submission of this matter to compulsory arbitration, plus interest and costs of suit. DATE: March :37 2001 RESPECTFULLY SUBMITTED, BOSWELL, TINTNER, PICCOLA & WICKERSHAM BY: Brig~rd, .<'O.~ Esquire{,,/ Attorney for Plaintiff Grandview Surgery & Laser Center HEALTHSOUTH GRANDVIEW SURGERY AND LASER CENTER 205 GrandviewAvenue · Camp Hill, Pennsy~nia 17011,717 731.5444 Pa ,, icn: 194-58-5629 RE~)hI~I~&~ PA~I'Y NAME AND ADDRE~ IF DIFFERENT FROM ABOVE F!~XIX~, CAROLINE . 807 N W.M_YL-f S-f, :VdECI-I.~ICSBURG, PA 17055 ID: 18623 ~A~ IAI"rAc~ I C.I. 'l' i ~=r, TO eAU. I WU. aE HErE I 'dg: 15 IWORKI~aONE '1 ] '1 ~ 7 t, ¢ - 2 o ~: 8 I RESPONSIBI.,E PAriTY PHONE ~TION *i'O RE~K3NS~_E PARTY RE~=ONSIBLE PARTY S~N RESPONSIBLE PAFf'r~ EMI~.OY~R SELl-- 194-5S-5629 194-58-5029-01 10!3. ] [::001 335D27o ~NSU~D'S E~=U:)YER ANO ~qS I.D..~/5~N I OFIOUPit I INSURED'S E~41=~OY-=R AND PHONE D~MLrI'H, MD, WILLIAM, W. I;;XAGNOS~S I=~IOCK;)~'D 8UROEFIY(1.1NE 1) EXCISIONAL BIOPSY OF: RIGItT INDEX FINGER SOFT TISSUE .MASS FINANCIAL AGREEMENT, ASSIGNMENT OF BENEFITS AND RELEASE OF RECORD(S) hereby assign to and authorize payment directly to the facility named above (the "facility") of all benefits due me under Medicare, Medicaid, or any insurance policy providing ben- efits for facility charges, for services rendered by the facility. photostatic copy of this agreement shall be considered effective and valid as the original. irrevoctblv agree that employees the facility may agents, disclose, including to the entities exlent allowed contract by law, my same medical~and provide financial quality record to (a) any affiliate of (b) the facility, specifically including HEALTHSOUTH 3orporatlof~ and its and under with to and/or utilization review; any person or entity which may be liable under :ontrac?r-- by law to the facility or to me, or any person or entity responsible for all or part of-the facility's charges, specifically including any insurance company or their agents or ~mployees; (c) any person or entity to whom I have been referred by the facility or by my physician for continued care; (d) any physician treating, consulting or otherwise performing ~ervices for me, including his or her employees and agents; (e) the Health Care Financing Administration, any other governmental or accrediting agency, or their agents or employ- ~eS. ~.11 facility charges are due and owing at discharge. In consideration of the services to be rendered, to the extent not expressly prohibited by law or by the contract between the facil- ty and my third party payor. I HEREBY AGREE, WHETHER I AM SIGNING AS PATIENT OR GUARANTOR, TO PAY ALL SUMS DUE THE FACILITY AT THE USUAL AND CUSTOMARY CHARGE OF THE FACIUTY. I hereby waive all claims of exemption. Should the account be referred to an attorney or collection agency for collection, I shall pay reasonable attorney's fees and :ollection expenses whether suit is filed or not. Belinquent accounts and amounts (those not paid within 60 days from the date of service) may bear interest on the unpaid amount up to the maximum amount allowed by law. I understand that I am financially responsible for charges not paid within said 60 days and for charges not covered by this assignment. understand that the facility files for reimbursement from my insurer or other payor as a courtesy, and failure on the part of the insurer to make payment shall not relieve me of my 3bligation to pay the facility. certify that I am the patient or that I am financially responsible for the services rendered and do hereby unconditionally guaranty the payment of all amounts when and as due. --acility employees are NOT able to define your insurance coverage. If you have coverage questions, you are advised to call your insurance carrier. ;AUTION~ DO NOT SIGN '~ISA~I:INLESS YOU UNDERSTAND ITS CONTENTS, DATE DATE GUARANTOR ~ DATE GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF Vo CAROLINE A. PICKING, DEFENDANT IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYLVANIA NO. 01-1479 CIVIL : ._ : CIVIL ACTION - LAW VERIFICATION I, Doris West, on behalf of Plaintiff, hereby verify that the facts contained in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are subject to the penalties of 18 Pa.C.S.A. §4904 relating to unswom falsification to attthorities. DORIS WEST DATE: GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFENDANT IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYLVANIA NO. 01-1479 CIVIL _. ; : CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, Denise L. Foster, Paralegal, do hereby certify that I have served a true and correct copy of the Complaint on the folloxving: Method of Service: First class mail l/Certified mail Other Caroline A. Picking 6243 Stanford Court Mechancisburg, PA 17055 BOSWELL, T1NTNER, PICCOLA & WICKERSHAM B Y: ~L .~o st er,~p a~l~l~e g~a'l''' DATE: March 27, 2001 Explanation of Benefits Page 1 of 1 HealthAssurance® 2575 Interstate Drive Harrisburg, PA 17110 THIS IS NOT A BILL Picking, Caroline A 6243 STANFORD COURT MECHANICSBURG, PA 17055-0000 Payments made on behalf of: HEALTHASSURANCE Patient: Group Name: ID Number: Claim Number: Date: Provider: Payee: Picking, Caroline A Picking, Caroline A HECHT COMPANY- CCPPO/PART-TIME 194585629 21979056 05/19/00 GRANDVIEW SURGERY CENTER GRANDVIEW SURGERY CENTER This is a statement of benefits only. If you did not already pay at the time of service, please contact provider listed above to make payment arrangements. Procedure Date of Service Total Ineligible Amount Amount Amount Amount Code/Description From/To Charge Amount/Code at 100% at 0% at 0% at 0% 26160 10/01/99 SURGERY 10/01/99 2, 159.92 2, 159.92 525 0.00 0.00 0.00 0.00 8B304 10/01/99 LAB/PATHOLOGY 10/01/99 281.00 281.00 525 0.00 0.00 0.00 0.00 Totals: 2,440.92 2,440.92 0.00 0.00 0.00 0.00 Covered Amount Less Deductible Less CoPay/Coinsurance Benefit Total Benefit Paid Member Responsibility Description of Remarks/Benefits 525: INELIGIBLE ON DATE OF SERVICE Grievance Review Process A covered individual has the right to appeal a denied claim through the Grievance Review Process. If you wish to appeal a denial decision, contact the Member Services Department at 1-800-788-8445. 0.00 0.00 0.00 0.00 0.00 2,440.92 Explanation of Benefits Page 1 of 1 HealthAssurance® 2575 Interstate Drive Harrisburg, PA 17110 THIS IS NOT A BILL Picking, Caroline A 6243 STANFORD COURT MECHANICSBURG, PA 17055-0000 Payments made on behalf of: HEALTHASSURANCE Insured: Petient: Group N-me: ID Number: Claim Number: Dete: Provider: Payee: Picking, Caroline A Picking, Caroline A HECHT COMPANY- CCPPO/PART-TIME 194585629 21979056 05/19/00 GRANDVIEW SURGERY CENTER GRANDVZEW SURGERY CENTER This is s statement of benefits only· If you did not already pay et the time of service, please contact provider II,ted above to make payment arrangements. Procedum Date of Sewice Total Code/Description From/To Charge 26160 10/01/99 SURGERY 10/01/99 2,159.92 88304 10/01/99 LAB/PATHOLOGY 10/01/99 281.00 Totals: Description of Remarks/Benefits 2,440.92 Ineligible .N~ount ~nount Amount ,N~ount · Amount/Code at 100% at 0% at 0% et 0% 2,159.92 525 0.00 0.00 0.00 0.00 281.00 525 0.00 0.00 0.00 0.00 2,440.92 0.00 0.00 0.00 0.00 Covered Amount Less Deductible Less CoPay/Coinsurance Benefit Total Benefit Paid Member Responsibility 0.00 0.00 0.00 0.00 0.00 2,440.92 525: INELIGIBLE ON DATE OF SERVICE Grievance Review Process A covered individual has the right to appeal a denied claim through the Grievance Review Process. If you wish to appeal a denial decision, contact the Member Services Department at 1-800-788-8445. CERTIFICATE OF SERVICE I hereby certify that I am this day serving a copy of the foregoing Complaint of Defendant Caroline A. Picking Against Additional Defendant HealthAssurence, Inc., upon the person(s) and in the manner indicated below, which service satisfies the requirements of the Pennsylvania Rules of Civil Procedure, by depositing a copy of same in the United States Mail, first-class postage prepaid, addressed as follows: Brigid Q. Alford, Esquire Boswell, Titner, Picolla & Wickersham 315 North Front Street Harrisburg, PA 17108-0741 Counsel for Plaintiffs Service via Sheriff of Cumberland County HealthAssurance, Inc. 2575 Interstate Drive Harrisburg, PA 17110 McKissock & Hoffman, P.C. Supreme Court I.D. No. 36818 Edwin A.D. Schwartz, Esquire Supreme Court I.D. No. 75902 105 North Front Street Suite 205 Harrisburg, PA 17101 Telephone: (717) 234-0103 Attorneys for Defendant, Caroline A. Picking Brigid Q. Alford, Esquire Sul~eme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 315 N. Front Street PO Box 741 Harrisburg, PA 17108-0741 (717) 236-9377 Attorneys for Plaintiff GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA : NO. 01-1479 CIVIL : CIVIL ACTION - LAW PLAINTIFF'S REPLY TO NEW MATTER OF DEFENDANT PLAINTIFF, Grandview Surgery & Laser Center, by its attorneys, Bfigid Q. Alford, Esquire, and Boswell, Tintner, Piccola & Wickcrsham, and Replies to the New Matter of Defendant, Caroline A. Picking, as follows: Plaintiff incorporates herein by reference it averments in Paragraphs 1-11 of its 12. Complaint. 13. Defendant's Joinder Complaint is directed to a party other than the Plaintiff and as same requires no response from Plaintiff. By way of further reply, Plaintiff incorporates herein by reference the factual averments sent for in the Complaint in Chief. RESPECTFULLY SUBMITTED, BOSWELL, TINTNER, PICCOLA & WICKERSHAM B~gid~. Alfo;d, Esq~llre Attorney for Plaintiff~'~ Grandview Surgery & Laser Center DATE: April~, 2001 GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA : NO. 01-1479 CIVIL : CIVIL ACTION - LAW VERIFICATION I, Doris West, on behalf of Plaintiff, hereby verify that the facts contained in the foregoing Reply to New Matter are tree and correct to the best of my knowledge, information and belief. I understand that false statements herein are subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. DORIS WEST GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA : NO. 01-1479 CIVIL : CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, Denise L. Foster, Paralegal, do hereby certify that I have served a true and correct copy of the Reply to New Matter on the following: B. Craig Black, Esquire McKissock & Hoffman 105 N. Front Street Suite 205 Harrisburg, PA 17101 Attorneys for Caroline A. Picking Health Assurance, Inc. 2575 Interstate Drive Harrisburg, PA 17110 Method of/Service: J First class mail Certified mail Other BOS~IN~I2qER, PICCOLA & WICKERSHAM DATE: April~0, 2001 GRANDVIEW SURGICAL & LASER CENTER, Plaintiff · IN THE COURT OF COMMON PLEAS · CUMBERLAND COUNTY, PENNSYLVANIA CAROLINE PICKING, Defendant V. HEALTHASSURANCE, INC., Additional Defendant · NO. 01-1479 CIVIL · CIVIL ACTION - LAW PRAECIPE FOR ENTRY OF APPEARANCE Please enter the appearance of the undersigned on behalf of Additional Defendant, HealthAssurance, Inc., in the above-captioned matter. Kespectfully submitted, TUCKER ARENSBERG & SWARTZ Dated: By: 111 North Front Street P.O. Box 889 Harrisburg, PA 17108-0889 (717) 234-4121 Attorney for Additional Defendant HealthAssurance, Inc. 39722.1 CERTIFICATE OF SERVICE ANDNOW, this //]/{~ dayof ~~-- ,2001, PAULAJ. BEITER, for the firm of TUCKER ARENSBERG & SWARTZ, attorneys for Additional Defendant, hereby certify that I have this day served the within document by depositing a copy of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Brigid Q. Alford, Esquire Boswell, Tintner, Piccola & Wickersham 315 North Front Street P.O. Box 741 Harrisburg, PA 17108-0741 Attorney for Plaintiff, Grandview Surgery & Laser Center B. Craig Black, Esquire McKissock & Hoffman 105 North Front Street, Suite 205 Harrisburg, PA 17101 Attorney for Defendant, Caroline A. Picking P~ULA J. I~EITER SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2001-01479 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND GRANDVIEW SURGERY & LASER VS PICKING CAROLINE A R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named ADD'TL DEFEND. , to wit: HEALTHASSURANCE INC but was unable to locate Them deputized the sheriff of DAUPHIN in his bailiwick. He therefore County, Pennsylvania, to serve the within COMPLAINT JOINING ADDL On May 9th , 2001 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: Docketing Out of County Surcharge DEP. DAUPHIN CO 18.00 9.00 10.00 29.25 .00 66.25 05/09/2001 CAROLINE PICKING R/ Thomas Kline Sheriff of Cumberland County Sworn and subscribed to before me this day of ~ A.D. Prothonotary Mazy ~ane Snyder peal Estate Deputy William T. Tully Solicito~ a Dauphin CountY. 17101 Harrisburg, pennsylYama ph: (717) 25%2660 fax: (717) 25%2889 Jack Lotwick Commonwealth of Pennsylvania : County of Dauphin Daniel Basile Chief DepUt~ 2001 Michael W. Rinehart Assistant chief Dept~ Sheriff GRANDVIEW suRGICAL & LASBR cENTER vs HEALTHASSURANCE INC sheriff's Return _ -2001 No. 1133-T oTHER couNTY NO. 01-1479 at l:40PM served the within upon by personally handing 1 true attested copy(ies) and making known AND NOW: April 27, NOTICE & COMPLAINT IN cIVIL ACTION HEALTHASSURANCE INC to coLLEEN FICKES, HUMAN RESOURCES of the original NOTICE & coMPLAINT IN cIVIL ACTION to him/her the contents thereof at 2575 iNTERSTATE DRIVE HBG, PA 17110-0000 ~wora a So Answers, swor~ and s~bscribed to ~/~ before me this 30TH day of APRIL, 2001 Pa. PROTHONOTARY sheriff's costs: $29.25 PD 04/24/2001 RcPT NO 149039 T GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF V. CAROLINE A. PICKING, DEFEND~N~ v. HEALTHASSURANCE, INC., ADDITIONAL DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 01-1479 C~V~ ~X RULE 1312-I. The Petition for Appointment of Arbitrators shall be substantially in the following form: PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Briqid O. A1 ford. Esquire. , counsel for the plaintiff/d~fe~m~in the above action (or actions), respectfully represents that: 1. The above-captioned action (~m) is :~am~ at issue. 2. The claim of the plaintiff in the action is $_. 3,2 4 0.2 0 The counterclaim of the defendant in the action is The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators: Brigid Q. Alford/Dennis R, Shaffer/B. Craig Black WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Resp.ectfull~y submit,/x.. ^ ORDER OF COURT AND ,N OW,,.J ,ff-~./~gff/Z/j o~9 ._,fi'/ ,rln)~p :;/.;.~h consideration o f the , f°reg°ing petiti..°n, ~~-~J - ~~/ Esq.,/~/~,ffcff~t.,~/ ~ actions) ~ ~d~r. ~ ~ ~ _. , ~sq., ~ appointed ~bitrators in ~e above captioned action (or By the Co '~N~A"~SNN3d GRANDVIEW SURGICAL and · IN THE COURT OF COMMON PLEAS OF LASER CENTER ' CUMBERLAND COUNTY, PENNSYLVANIA V. 01-1479 CIVIL CAROLINE PICKING, HEALTH ASSURANCE, INC. IN RE: ARBITRATION ORDER OF COURT AND NOW, December 16, 2002, the Court having been informed that the above-captioned case has settled prior to hearing, the panel of arbitrators previously appointed is vacated, and William A. Yocum, Esquire, Chairman of the Arbitration Panel, shall be paid the sum of $50.00. By the Court, G. Edward Schweikert IV, Esquire B. Craig Black, Esquire William A. Yocum, Esquire Dennis R. Sheaffer, Esquire Charles Zaleski, Esquire Barbara Zimmerman, Esquire Court Administrator LEONARD TINTNER JEF'FREY E. PICCOLA RICHARD B, WICKERSHAM JEFFREY R. BOSWELL BRIGID Q. ALF'ORD G. EDWARD SCHWEIKERT, IV BOSWELL, TINTNER, PICCOLA & WICKERSHAM COUNSELORS AT LAW 315 NOZTH FRONT STreET P.O. Box 741 HARRISBURG, PA 17108-0741 {7171 236-9377 FAX 17171 236-9316 btpw@att.net WILLIAM D. BOSWELL II943 - 19991 December 12, 2002 William A. Yocum, Esquire 3001 Market Street Camp Hill, PA 17011 Dear Mr. Yocum: Grandview Surgery v. Pickhtg Case No. 01-1479 Civil Cumberland County Court of Common Pleas As you know, the above-referenced case is scheduled for arbitration before you on December 18, 2002, at 11:00 am. Please be advised that my client, Grandview Surgery, has settled its claim against Defendant Picking and that the arbitration date is no longer required. I will take the necessary steps to discontinue my client's action after all settlement funds have been received. Unless I hear otherwise from you, I will assume that no further action on my part is necessary to cancel the upcoming arbitration. Thank you for your assistance in this matter and should you require any further information, please feel free to contact me. GES/adp cc: B. Craig Black, Esquire Dennis R. Sheaffer, Esquire Charles Zaleski, Esquire Barbara Zimmerman, Esquire Ve truly yours, . ward Schweikert, IV WILLIAM A. YOCUM ATTORNEY AT LAW 3001 MARKET STREET CAMP HILL. PA 17011 AREA CODE 717 TELEPHONE 761-5041 December 13, 2002 Hon. George E. Hoffer, President Judge 1 Courthouse Square Carlisle, PA 17013-3387 Re: Arbitration Hearing Grandview Surgery v. Picking Case No. - 01-1479 Cumberland County Court of Common Pleas Dear Judge Hoffer: After you appointed me as chairman of the above referenced Arbitration Board, I set the hearing date for December 18, 2002 amd this day received a letter alleging settlement from Plaintiff's attorney, a copy of which is here- with enclosed. The Court Administrator's Office was ~otified and the hearing was cancelled. Ail parties have been notified by Plaintiff attorney's letter of that settlement but there is nothing on the record to indicate, concurrence by the attorney for the Defendant, Caroline A. Picking, who has filed claims for Fraud and Misrepresentation, Breach of Contract and Unfair Trade Practice and Consumer Protection Law Claims against Additional Defendant, Health Assurance, Inc. Defendant's attorney was not available by telephone this afternoon. I am returning the file. Perhaps an order vacating the Arbitration Panel would be appropriate in light of the fact that Plaintiff petitioned for the appointment of arbitrators in the first place and is alleging settlement. Very truly yours William A. Y~um Brigid Q. Alford, Esquire Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 315 N. Front Street PO Box 741 Harrisburg, PA ! 7 ! 08-0741 (717) 236-9377 Attorneys for Plaintiff GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF Ve CAROLINE A. PICKING, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA : NO. 01-1479 CIVIL : CIVIL ACTION - LAW PRAECIPE TO SETTLE AND DISCONTINLrE TO THE PROTHONOTARY: Kindly mark the above-matter as settled and discontinued. BOSWELL, TINTNER, PICCOLA & WICKERSHAM By: Brigid.' ~--Q. ~lford, JEsquir~} DATE: December 19, 2002