HomeMy WebLinkAbout03-12-07
IN RE: Estate of JANE B.
SMITH, Deceased
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: NO. 2006-01000
PETITION FOR APPROVAL OF PROPOSED SETTLEMENT OF
SURVIVAL CLAIM AND DISTRIBUTION OF FUNDS
AND NOW, pursuant to 20 Pa.C.S. ~ 3323, Nancy J. Stinson, Executrix of the Estate of
Jane B. Smith, by and through her attorney, George J. Costopoulos, Esquire, petitions this
Honorable Court for approval of the proposed settlement and distribution of the survival claim
held by the Estate of Jane B. Smith, and avers that:
1. Petitioner is Nancy J. Stinson, the Executrix of the Estate of Jane B. Smith,
who died testate on November 3,2006 having ftrst made her last will and testament dated April
19, 1998. A copy of decedent's last will and testament is attached hereto as Exhibit "A."
2. On November 14, 2006, Petitioner was granted Letters Testamentary on
decedent's estate, docketed at No. 2006-01000, by the Register of Wills of Cumberland County,
Pennsylvania. A copy of the Certiftcate of Grant of Letters is attached hereto as Exhibit "B."
3. On December 1 0, 2004, prior to her death, decedent sustained a fractured
humerus and related personal injuries due to a fall down incident while a business:J.nvitee oti1he
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premises of Weis Markets in Mechanicsburg, Pennsylvania.
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4.
On January 5, 2005, decedent retained the undersigned counsel to neg<l~ate ~':'
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settlement and/or to institute legal proceedings for damages resulting from her fulldbwn incident
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against any responsible person, ftrm, corporation or entity. A copy of the fee agreement is 1,., \
attached hereto as Exhibit "C."
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5. On November 3, 2006, decedent passed away from a cause unrelated to her fall
down incident. As such, decedent's personal injury claim became a survival claim held by
decedent's estate pursuant to 42 Pa.C.S.A. 9 8302. There is no wrongful death action for which
damages can be recovered under 42 Pa.C.S.A. 9 8301.
6. Following decedent's death, the undersigned counsel negotiated a proposed
settlement of this matter in the amount of $20,000.00 with Weis Markets, Incorporated through
its third party claims administrator, PMA Management Corporation. A copy of the proposed
Settlement Agreement and Release is attached hereto as Exhibit "D."
7. This settlement was negotiated without the need of a lawsuit, and counsel is of the
opinion that the proposed settlement is reasonable in light of the contested liability issues in this
matter, and based on previous settlements in comparable cases. Petitioner is also of the opinion
that the proposed settlement is reasonable, and has consented thereto.
8. Correspondingly, Petitioner now requests that this Honorable Court approve the
proposed settlement with Weis Markets, Incorporated and PMA Management Corporation for the
amount of $20,000.00.
9 From the proposed settlement of $20,000.00, Petitioner additionally seeks
approval from this Honorable Court for a distribution to the undersigned counsel consistent with
the attached contingent fee agreement, which provides for counsel fees in the amount of33 %
percent, or $6,666.66, plus costs in the amount of $244.45. An itemization of counsel's
disbursements is attached hereto as Exhibit "E."
10. From the balance of the proposed settlement, $13,088.89, Petitioner next asks that
this Court approve a distribution to Medicare for $708.93, the amount of Medicare's subrogation
2
lien for medical expenses it paid for decedent's fall down injuries. A copy of Medicare's letter
confirming its subrogation lien is attached hereto as Exhibit "F."
11. As there are no other known liens, claims or debts against this recovery, Petitioner
lastly requests that the remaining amount of the proposed settlement, $12,379.96, be approved
for distribution to the gross probate Estate of Jane B. Smith and dispersed in accordance with
decedent's last will and testament attached hereto as Exhibit "A."
WHEREFORE, Petitioner respectfully requests that this Honorable Court issue an Order
approving the proposed settlement ofthe survival claim held by the Estate of Jane B. Smith,
along with the proposed distribution as set forth above in the attached proposed Order.
RESPECTFULLY SUBMITTED:
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George J. Costopoulos, Esquire
LD. No. 78423
10 East Louther Street, First Floor
Carlisle, Pennsylvania 17013
Phone: (717) 243-0407
Attorney for Petitioner
Date: 3 /' 12..-~ '=l-
3
VERIFICATION
I, Nancy J. Stinson, Executrix of the Estate of Jane B. Smith, do hereby verifY that the
statements made in the foregoing Petition for Approval of Proposed Settlement of Survival
Claim and Distribution of Funds are true and correct. I understand that any false statements
herein are made subject to the penalties of 18 Pa.C.S. ~ 4904 relating to unsworn falsification to
authorities.
Date: 3<'"""/ L -04--
LAST WILL AND TESTAMENT
OF
JANE B. SMITH
I, JANE B. SMITH, A RESIDENT OF 2016 MILL TOWN ROAD, CAMP HILL,
CUMBERLAND COUNTY, PENNSYL VANIA, BEING OF SOUND MIND AND
MEMORY, DO HEREBY MAKE, PUBLISH AND DECLARE THIS TO BE MY LAST
WILL AND TESTAMENT, AND HEREBY EXPRESSLY REVOKE ALL PRIOR
WILLS AND CODICILS AND WRITINGS IN THE NATURE TIIEREOF,
HERETOFORE MADE BY ME.
1. I DECLARE IRATI RA VB TWO CHILDREN NOW LIVING: NANCY
SMITH STINSON, OF 18 WINDEHURST DRIVE, MADISON, NJ 17940; AND ERIC
M. SMITH, SR., OF 4946 MEGANWOOD LANE, JACKSONVILLE, FL 32257; AND
THA T ALL REFERENCES IN THIS WILL TO "MY CHILDREN" ARE
REFERENCES TO THEM.
II. I DECLARE THAT I HA VB THREE GRANDCHILDREN NOW LIVING:
ERIC M. SMITH, JR., OF 4946 MEGANWOOD LANE, JACKSONVILLE, FL 32257;
JAMES D. SMITI-I, OF 4946 MEGANWOOD LANE, JACKSONVILLE, FL 32257;
AND DANIEL R. SMITH, OF 18 WINDEHURST DRIVE, MADISON, NJ 17940; AND
THAT ALL REFERENCES IN THIS WILL TO "MY GRANDCHILDREN" ARE
REFERENCES TO THEM.
III. I DECLARE TIIA T I HAVE TWO BROTHERS NOW LIVING, RICHARD
P. BLACK, OF P.O. BOX 269, PETERSBURG, PA 16669; AND WILLIAM G.
BLACK, OF 3108 BLUE DRIVE, SUPPLY, NC 28462; AND THAT ALL
REFERENCES IN THIS WILL TO "MY BROTHERS" ARE REFERENCES TO
1HEM.
IV. I GIVE, DEVISE AND BEQUEATH THE AMOUNT OF $10,000.00 TO
EACH OF MY GRANDCHILDREN WHO SHALL SURVIVE ME PROVIDED,
HOWEVER, THAT IF ANY OF MY GRANDCHILDREN SHALL PREDECEASE ME
BUT ISSUE OF SUCH GRANDCHILD SHALL SURVIVE ME, THEN THE SHARE
OF MY ESTATE WHICH OTHERWISE WOULD HA VB GONE TO SUCH
GRANDCHILD OF MINE SHALL BE DIVIDED AMONG THE ISSUE OF SUCH
GRANDCHILD OF MINE IN EQUAL SHARES.
V. I GIVE, DEVISE AND BEQUEATH THE AMOUNT OF $5,000.00 TO
EACH OF MY BROTHERS WHO SHALL SURVIVE ME PROVIDED, HOWEVER,
TI-IA T IF MY BROTIIERRICHARD SHALL PREDECEASE ME BUT HE SHALL BE
SURVIVED BY HIS WIFE FRANCESCA, THEN THE SHARE OF MY ESTATE
WHICH OTHERWISE WOULD HA VB GONE TO RICHARD SHALL GO TO HIS
WIFE FRANCESCA, PROVIDED THAT SHE SHALL SURVIVE ME; AND THAT IF
MY BROTIIER WILLIAM SHALL PREDECEASE tvrn BUT HE SHALL BE
SURVIVED BY HIS WIFE CAROLYN, THEN THE SHARE OF MY ESTATE
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WHICH OTHERWISE WOULD HAVE GONE TO ~ -SfI;M;"L GO TO HIS
WIFE CAROL YN, PROVIDED THAT SHE SHALL SURVIVE tvrn.
VI. I GIVE, DEVISE, AND BEQUEATH ALL MY TANGIBLE ARTICLES OF
A PERSONAL NA TORE TO MY CIDLDREN THEN LIVING IN EQUAL SHARES.
IT IS MY INTENTION TO LEAVE IN MY SAFE DEPOSIT BOX AT THE TItvrn OF
MY DEA TII FOR TIIE INFORMATION OF MY CHILDREN A LIST INDICATING
PARTICULAR TANGIBLE ARTICLES OF A PERSONAL NATURE THAT I
WOULD LIKE TO BE GIVEN BY THEM TO CERTAIN PERSONS. IT IS MY WISH,
BUT NOT MY DIRECTION THAT THEY USE THAT LIST AS A GUIDE IN
DISPOSING OF THE TANGIBLE ARTICLES HEREINABOVE BEQUEATIIED TO
THEM.
VII. I GIVE, DEVISE AND BEQUEATH ALL TIIE REMAINDER OF MY
ESTATE TO MY CHILDREN WHO SURVIVE tvrn, IN EQUAL SHARES
PROVIDED, HOWEVER., THAT IF ONE OR BOTH OF MY CIDLDREN SHALL
PREDECEASE tvrn BUT ISSUE OF SUCH CHILD SHALL SURVIVE ME, TIIEN
TIIE SHARE OF MY ESTATE WHICH OTHERWISE WOULD HAVE GONE TO
SUCH CIDLD OF MINE SHALL PASS PER STIRPES TO THE ISSUE WHO
SURVIVE ME OF THE DECEASED CHILD OF MINE.
VIII. ALL SHARES OF PRINCIPAL AND INCOME HEREBY GIVEN SHALL
UNTIL ACTUAL DISTRIBUTION TO THE BENEFICIARIES BE FREE OF
CONTRACTS, DEBTS, ANTICIPATIONS, ASSIGNMENTS, PLEDGES OR
OBLIGATIONS OF ANY BENEFICIARY AND TIlE SAME SHALL NOT BE
SUBJECT TO LEVY, EXECUTION OR ATTACHMENT WInLE IN THE
POSSESSION OF MY PERSONAL REPRESENTATIVE.
IX. I DIRECT THAT ALL INHERITANCE TAXES THAT MAYBE
ASSESSED IN CONSEQUENCE OF MY DEATH SHALL BE PAID FROM MY
RESIDUARY ESTATE AS A PART OF THE EXPENSES OF THE
ADMINISTRATION OF MY ESTATE.
X. IN ADDITION TO TIlE POWERS CONFERRED BY LAW, MY
PERSONAL REPRESENTATIVE SHALL HAVE THE DISCRETIONARY POWERS
TO RETAIN FOR DISTRIBUTION IN KIND ALL MY PROPERTY OR TO SELL
ALL OR ANY PART OF SUCH PROPERTY UPON SUCH TERMS AS HE MA Y
DEEM ADVISABLE; TO EXCHANGE OR LEASE FOR ANY PERIOD OF TIME
ANY OF MY PROPERTY; TO COMPROMISE ANY CLAIM OR CONTROVERSY
WITHOUT COURT APPROVAL; TO MAKE DISTRIBUTIONS IN CASH OR IN
KIND; AND TO DETERMINE THE VALUE OF ALL MY PROPERTY.
XI. I HEREBY APPOINT MY DAUGHTER NANCY AS TIIE EXECUTRIX
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OF MY ESTATE, PROVIDED THAT HE SURVIVES ME. IN THE EVENT THAT
MY DAUGHTER DOES NOT SURVIVE ME, I HEREBY APPOINT MY SON ERIC
AS EXECUTOR OF MY ESTATE.
XII. I DIRECT THAT MY PERSONAL REPRESENT A TIVB SHALL NOT BE
REQUIRED TO GIVE BOND FOR THE FAITHFUL PERFORMANCE OF HIS
DUTIES IN ANY JURISDICTION.
IN WITNESS WHEREOF, I, JANE B. SMIill, TIlE TESTATRIX ABOVE
NAMED, HA VB HEREUNTO SUBSCRIBED MY SIGNATURE AND AFFIXED MY
SEAL THIS 19th DAY OF APRIL, 1998.
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8 _ A ~&:./ (SEAL)
THE FORGOING INSTRUMENT WAS ON THE DATE TIIEREOF
SUBSCRIBED AT THE END THEREOF BY JANE B. SMITH AND BY HER
SIGNED, SEALED, PUBLISHED AND DECLARED TO BE HER WILL IN TIlE
PRESENCE OF US AND EACH OF US, WHO UPON HER REQUEST, IN HER
PRESENCE, AND IN THE PRESENCE OF EACH OTHER, HA VB SUBSCRIBED
OUR NAMES AND ADDRESSES AS ATTESTING WITNESSES HERETO.
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ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYL VANIA }
} ss.
COUNTY OF CUMBERLAND }
I, JANE B. SMITH, the testatrix, whose name is signed to the foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I
signed and executed the instrument as my Last Will; that I signed it willingly and that I
signed it as my free and voluntary act for the purposes therein expressed.
Sworn to or affirmed and acknowledged before me by JANE B. SMITH, the
testatrix, this 19th day of April, 1998.
William H. Andring, Esq.
Pennsylvania
AFFIDA VIT
COMMONWEAL TII OF PENNSYL VANIA }
} ss.
COUNTY OF CUMBERLAND }
We, · . ~ and.::50 t "'" r S It t/C..!:j , the
witnesses whose names are signed to th ttached or foregoing instrument, bemg duly
qualified according to law, do depose and say that we were present and saw the testatrix
sign and execute the instrument as her Last Will; that the testatrix signed willingly and
executed it as her free and voluntary act for the purposes therein expressed; that each
subscribing witness in the hearing and sight of the testatrix signed the will as a witness;
and that to the best of our knowledge the testatrix was at that time 18 or more years of
age, of sound mind and under no constraint or undue influence.
Sworn to or affirmed and subscribed to before me by e t1! l1.dJ ...-
and ...:To'- fI.. r: tf ~ (/67 ' witnesses, this 1 ~ day of April, 1998.
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Witness . - ~
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William H. Andring, Esq.
Pennsylvania
ATTORNEY'S CERTIEICATION
COMMONWEALTH OF PENNSYLVANIA
}
} ss.
}
COUNTY OF DAUPIIIN tu HBEl;)LAlY))
On this, the ~ day of (J Uf1 0 , 1998, before me
(;gyfJ(;A;vA/ ;;;. . ' the undersigned officer, personally appeared William H.
Andring, known to me or satisfactorily proven to be a member of the bar of the highest court of
Pennsylvania, and certified that he was personally present when the forgoing acknowledgment
and affidavit were signed by the testatrix and witnesses.
In witness whereof, I hereunto set my hand and official seal.
4OZSM^dlfrfJ
NOTARIAL SEAL
GEORGANN E. KEGG,NotarY Public
Camp Hint Cumber1and County
My CommIssIon expires Feb. 29, 2000
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REGISTER OF WILLS
CUMBERLAND County, Pennsylvania
CERTIFrCATE OF GRANT OF LETTERS
No. 2006-01000
Es ta te Of: JANE B SMITH
PA No. 21-06- 1000
(First. Middle, Lastl
Late Of:
LOWER ALLEN TOWNSHIP
CUMBERLAND COUNTY
Deceased
Social Securi ty No: 174-18-3883
WHEREAS, on the 14th day of November 2006 an instrument dated
April 19th 1998 was admitted to probate as the last will of
JANE B SMITH
(First, Middle. Last!
late of LOWER ALLEN TOWNSHIP, CUMBERLAND County,
who died on the 3rd day of November 2006 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
NANCY J STINSON
who has duly qualified as EXECU TOR (RIX)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYL VANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 14th day of November 2006.
/ cf
**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
WILLIAM C. COSTOPOULOS
DAVID J. FOSTER
LESLIE M. FIELDS
GEORGE H. MATANGOS
GEORGE 1. COSTOPOULOS (OfCounseI)
COSTOPOULOS, FOSTER & FIELDS
ATTORNEYS AND COUNSELORS AT LAW
10 EAST LOUTHER STREET
FIRST FLOOR
CARLISLE, PENNSYLVANIA 17013
TELEPHONE 243-0407
AREA CODE 717
FAX 243- 0950
Power of Attorney
and
Contingent Fee Agreement
I, L {)( It-( /~.~ ,~ , (hereinafter "client"), do hereby retain
Costopoulos, oster & Fields, 10 East Louther Street, First Floor, Carlisle, Pennsylvania 17013
(hereinafter "attorneys"), as my attorneys to negotiate for me a settlement or to institute for me in
my name any legal proceedings or action th~ in their judgn:t.ent are necessary in connection with
my claim for damages resulting from , atl -:&11,&1. t1- /iJIS:'", /2 It/. ,,~ , against any person,
firm, corporation or entity who may be responsible for my claim, and/or to obtain an amicable
settlement.
I hereby give to my attorneys a Power of Attorney to execute all documents connected
with the claim for the prosecution of which the attorney is retained, including pleadings,
contracts, commercial papers, settlement agreements, compromises and releases, verifications,
dismissals, orders, settlement checks and all other documents that I could properly execute in
connection with this lawsuit.
I agree to fully cooperate with my said attorneys in the prosecution of the claim that
comprises the subject matter of this Agreement. This includes, but is not limited to, making
myself available for legal proceedings and consultations with my said attorneys; keeping my said
attorneys informed as to my current mailing address, phone number and the current status of my
medical condition.
In consideration of the services performed and to be performed by attorneys, I agree to
pay attorneys' fees from the total amount recovered from any source a contingent fee of 33 1/3%.
Costs: It is understood that attorneys may advance out-of-pocket costs incurred by
attorneys in the investigation, prosecution, preparation and trial of this case. Such costs are to be
paid from my (the client's) share ofthe total amount recovered and include, but are not limited
to: photocopies; fax charges; postage; notaries; long distance telephone charges; mileage for
attorneys and staff; investigation charges; photographs; court costs; computer-based research
charges; medical records costs; fee for police report; deposition costs; expert witness fees;
stenographer costs; and, video deposition fees.
In the event that no recovery is obtained on this claim, the attorneys will make no charges
for their time or services. However, any costs or expenses that the attorneys may have advanced
on behalf of the claim must be paid by me upon request by said attorneys.
As one possible settlement option, I authorize the said attorneys to explore the possibility
of a structured settlement tnrough the use of deferred periodic payments. I agree that if my claim
is settled through such structure, the attorneys' fees may be paid directly to said attorneys from
the insurance company, either in one lump sum payment at settlement, or, at the sole option of
said attorneys and/or insurance company, deferred into future payments. However, in any event,
said attorneys' fees shall be calculated in the percentage as set forth above based upon the cost of
the structured settlement or present value thereof in accordance with applicable law.
All medical bills for which I am legally responsible and incurred as a result of my injuries
shall be chargeable to my share exclusively, unless otherwise paid by insurance.
Client agrees that, in the event that the investigation and discovery performed by
attorneys shall in the judgment of attorneys reveal that no meritorious claims exist on behalf of
client, then attorneys may withdraw from the further representation of the client in this matter.
Client and attorneys further agree that, in the event that client shall become dissatisfied with the
services of attorneys, client shall be permitted to discharge attorneys from their employment in
this matter. However, in the event that client elects to discharge attorneys, attorneys shall be
entitled to receive payment of fees from any recovery which client ultimately makes on these
claims. The fees payable to attorneys shall be in an amount which would reasonably and
equitably compensate attorneys for their efforts on behalf of client in the prosecution of the
claims. If client and attorneys are not able to reach an agreement as to the amount of those fees
at the time of discharge, then the matter shall be submitted to arbitration.
This Contingent Fee Agreement applies to all proceedings up to and including verdict or
decision at trial or arbitration. If, in the discretion of the attorneys, post-trial proceedings,
including appeals, are warranted, they will not be covered by this Contingent Fee Agreement and
a new fee agreement will be required by said attorneys.
And Now, on the day and year written below, the above Contingent Fee Agreement and
Power of Attorney has been read, approved, and understood by me and the receipt of a copy
thereof acknowledged. The terms set forth are agreeable.
Ov-
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CClient
Oeo ~e J. Costopoulos, Esquire
Date:
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I
Lemoyne Office: 831 Market Street, P.O. Box 222 . Lemoyne, P A 17043
(717) 731-2121. Fax (717) 761-4G31
CLAIM NUMBER: L880414919
PMA
Management
Corp.
GENERAL RELEASE
(PLEASE READ CAREFULLY!)
KNOW ALL MEN BY THESE PRESENTS, THAT I/WE NANCY J. STINSON, AS EXECUTRIX OF THE
ESTATE OF JANE B. SMITH, FOR THE SOLE CONSIDERATION OF TWENTY THOUSAND AND
NO/100S DOLLARS ($20,000.00) lawful money of the United States to me/us in hand paid by PMA
MANAGEMENT CORP. the receipt whereof is hereby acknowledged have remised, released and
forever discharged WEIS MARKETS, INC. and PMA MANAGEMENT CORP. and his/her/their heirs,
executors and administrators, their successors and assigns and any and all other persons and entities
(whether herein named or not) of and from all claims, demands, damages actions, cause of action, or
suits at law or in equity, or whatsoever kind of nature, for or because of any matter or thing done,
omitted or suffered to be done by the said WEIS MARKETS, INC. prior to and including the date
hereof, and particularly on account of all injuries both to person or property resulting or to result, from
an accident which occurred on or about the TENTH day of DECEMBER, 2004 at or near
MECHANICSBURG. PENNSYLVANIA.
It is understood and agreed that this settlement is not to be construed as an admission of liability on
the part of WEtS MARKETS, INC. and that this release contains the entire agreement between the
parties hereto, and the terms of this release are contractual and are not a mere recital.
I/We further state that I /We have carefully read the foregoing release and know the contents thereof,
and I/We sign the same as my/our own free act and deed.
IN WITNESS WHEREOF, I/We have hereunto set my/our hand and seal this
, A.D.,
day of
NANCY J. STINSON
In the presence of:
Commonwealth of Pennsylvania
County of
On the day of
SUBSCRIBER,
THE FOREGOING RELEASE
RECORDED AS SUCH.
, A.D., , BEFORE ME, THE
, WHO IN DUE FORM OF LAW ACKNOWLEDGED
TO BE AN ACT AND DEED AND DESIRED THE SAME BE
IN TESTIMONY WHEREOF, I HAVE HEREUNTO SET MY HAND AND SEAL THE DAY AND YEAR
AFORESAID.
A member of The PMA Group
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MSPRC
CENTERS ftxMEDlCARE & MEDICAID SERIIlCE5
4641MB 0.326
***AUTO**MIXED AADC 720- R:464 T:5 P:5 PC:4 F:3701_045249 02/22/2007
GEORGE COSTOPOULOS
10 E LOUTHER ST
CARLISLE PA 17013-3025
111.111111111111...11..1111.11111111111.1.1.1....11111..1...11
RE: Name: SMITH, JANE B
HIC#: 174183883A
Date of Incident: 12/10/2004
Debt Identification No.: 200624009000522
Demand Amount: $708.93
Dear Sir/Madam:
Please note that if we know that you have an attorney or other individual
representing you in this matter, we are sending him/her a copy of this letter. If you
have an attorney or other representative for this matter and his/her name is not
shown as a "cc" at the end of this letter (indicating that he/she is receiving a copy),
please contact us immediately. If you have any questions regarding this letter and
are represented by an attorney or other individual in this matter, you may wish to
talk to your representative before contacting us.
We are writing to you because we recently learned that you have made a liability claim
relating to an illness, injury or incident occurring on or about 12/10/2004 and
obtained a recovery. We have determined that you are required to repay the Medicare
program $708.93 for the cost of medical care it paid relating to your liability
recovery. (The term "recovery" includes a settlement, judgment, award or any other type
of recovery.)
We hope that you will find answers to some of the questions you may have about this
letter below. Parts I and II of this letter explain the federal law that requires you to pay
Medicare back and the way we determined the amount you are required to repay. We
have provided instructions for repaying Medicare in Part III of this letter. You have the
right to appeal our determination if you disagree with it, and you also have the right to
request that the Medicare program waive recovery of the amount you owe in full or in
part. Instructions for requesting waiver of recovery and appeal are provided in Part IV of
this letter. Part V of this letter explains the interest charges that apply if you do not repay
Medicare within sixty (60) days from the date of this letter and tells you about certain
actions Medicare may decide to take if you fail to repay the amount you owe. Finally,
Part VI identifies whom you should contact if you have questions about this letter.
I. Why am I required to repay Medicare?
You are required to repay Medicare because Medicare paid for medical care you received
related to your liability recovery. The Medicare Secondary Payer (MSP) law allows
Medicare to pay for medical care received by a Medicare beneficiary who has or may
have a liability claim. However, the law also requires Medicare to recover those
payments if payment ofa liability settlement, judgment, recovery, or award has been or
could be made. Congress passed the MSP law because it wanted to make sure that the
Medicare Trust Funds would have enough money to pay for medical care that
beneficiaries may need in the future. Congress decided that, if a liability recovery was
available to pay for a Medicare beneficiary's medical care, then that money should be
used to pay for the care and any amounts already paid by Medicare should be refunded to
the Medicare Trust Funds.
If you would like to read the MSP law, you can find it in Title 42 of the United States
Code, Section 1395y(b )(2). You can also find the regulations that explain how the
Medicare program recovers amounts it is owed under the MSP law in Title 42 of the
Code of Federal Regulations, beginning at Section 411.20. You can also learn more
about how the MSP law works by contacting your local Social Security office or by
visiting www.medicare.gov.
II. How did Medicare decide how much money I owe?
The Medicare program paid $1,082.01 for medical care related to your liability
recovery. We have enclosed a list of the payments Medicare made related to your
recovery with this letter. The Medicare program generally reduces the amount a
Medicare beneficiary is required to repay to take into account the costs (such as
attorney's fees) paid by the beneficiary to obtain his or her liability recovery. You can
find the formula we use to decide how much the amount of this reduction should be at
42 C.F.R., sub-section 411.37. We have applied the formula and determined that the
amount you owe Medicare is $708.93
This letter relates only to money paid from your current recovery. If, in the future, you
receive additional money from this liability recovery, or any other liability recovery, you
must let us know.
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III. What do I need to do to repay Medicare the amount I owe?
You must repay Medicare $708.93 within sixty (60) days of the date of this
letter 02/22/2007 . Please send a check or money order for $708.93 , made
payable to Medicare, to us at the address listed at the end of this letter. Please make sure
to include your name and Medicare number on the check or money order and include a
copy of this letter with your payment.
IV. What rights do I have if I disagree with the amount this letter says I owe or
think that I should not have to pay Medicare back for some other reason?
Right to Request a Waiver - You have the right to request that the Medicare program
waive recovery of the amount you owe in full or in part. Your right to request a waiver is
separate from your right to appeal our determination, and you may request both a waiver
and an appeal at the same time. The Medicare program may waive recovery of the
amount you owe if you can show that you meet both of the following conditions:
1. This overpayment (for purposes of requesting waiver of recovery, the amount
you owe is considered an overpayment) was not your fault, because the
information you gave us with your claims for Medicare benefits was correct and
complete as far as you knew; and when the Medicare payment was made, you
thought that it was the right payment;
AND
2. Paying back this money would cause financial hardship or would be unfair for
some other reason.
If you believe that both of these conditions apply to you, you should send us a letter that
explains why you think you should receive a waiver of the amount you owe. If you
request a waiver, we will send you a form asking for more specific intormation about
your income, assets, expenses, and the reasons why you believe you should receive a
waiver. lfwe are unable to grant your request for a waiver, we will send you a letter that
explains the reason(s) for our decision and the steps you will need to follow to appeal that
decision if it is less than fully favorable to you.
Ri2ht to Appeal - You also have the right to appeal our determination if you disagree
that you owe Medicare as explained in Part I of this letter, or if you disagree with the
amount that you owe Medicare $708.93 as explained in Part II of this letter. To file
an appeal, you should send us a letter explaining why you think the amount you owe
Medicare is incorrect and/or any reason(s) why you disagree with our determination.
Once we receive your request for appeal, we will decide whether our determination that
you must repay Medicare $708.93 is correct and send you a letter that explains
the reasons for our decision. Our letter will also explain the steps you will need to follow
to appeal that decision if it is less than fully favorable to you.
You have 120 days from receipt of this letter 02/22/2007 to file an appeal. We must
assume that you received this letter within five (5) days of the date of the letter 02/22/2007
unless you furnish us with proof to the contrary.
If you do not already have an attorney or other representative and you want help with
your appeal or request for waiver, you can have a friend, lawyer, or someone else help
you. Some lawyers do not charge unless you win your case. There are groups, such as
lawyer referral services that can help you find a lawyer. There are also groups, such as
legal aid services, that will provide free legal services if you qualify.
V. What happens if I do not repay Medicare the amount I owe?
Please note that, if you do not repay Medicare in full by 04/22/2007 , you will be
required to pay interest on any remaining balance, from the date of this letter, at a rate
of 12.5% per year. If the debt is not fully resolved within 60 days of the date of this
letter, interest is due and payable for each full 30 day period the debt remains unresolved.
By law, all payments are applied to interest first, principal second. You can find the
regulation that explains interest charges at 42 c.P.R., sub-section 411.24(m). To avoid
having to pay interest, you should repay Medicare in full within sixty (60) days of the
date of this letter, even if you decide to request a full or partial waiver of the amount you
owe or decide to appeal our determination (see Part IV) of this letter). If you receive a
waiver of recovery or if you are successful in appealing our decision, Medicare will
refund amounts you have already paid
If you are unable to repay Medicare in one payment, you may ask us to consider whether
to allow you to pay in regular installments. If you make installment payments, you
should be aware that your payments will be applied to any interest due first and then to
the outstanding principal amount.
You should also be aware that if you do not repay Medicare in full, it may decide to
recover any amounts you owe (including accrued interest) from any Social Security or
Railroad Retirement benefits to which you might otherwise be entitled, or from future
Medicare payments. Your failure to respond as requested within sixty (60) days of the
date of this letter may result in the initiation of additional recovery procedures without
further notice, including referral to the Department of Justice for legal action and/or the
Department of the Treasury for other collection actions. You should be aware that the
Debt Collection Improvement Act of 1996 requires Federal Agencies to refer debts to the
Department of the Treasury or its designated debt collection center for recovery actions
including collection by offset against any monies otherwise payable to the debtor by any
agency of the United States and through other collection methods. Under this and other
authorities (31 U.S.c. 3720A), the Internal Revenue Service may collect this debt by
offset against tax refunds owed to individuals or other entities.
RCDBL4
VI. Who should I contact if I have questions about this letter?
This office is the Medicare contractor responsible for handling your case. If you have
any questions about this letter, or questions about Medicare's recovery rights in general,
please contact MSPRC Liability at 1-866-677-7220 (TTY /TDD: 1-866-677-7294 for the
hearing and speech impaired) or the address listed below. Please also make sure that any
letters you send us include your name, your Medicare Health Insurance Claim Number
(this is the number found on your red, white and blue Medicare card), and the date of the
illness, injury or incident. Providing us with this information will help us respond more
quickly to any questions you may have.
Sincerely,
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Medicare Secondary Payer Recovery Contractor
MSPRC Liability
PO Box 33828
Detroit, MI 48232-3828
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_ Enclosure: Payment Summary Form
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- cc: GEORGE COSTOPOULOS
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