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HomeMy WebLinkAbout01-05198IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA FRANCES M. ROSARIO, as named beneficiary under the Group Life Insurance Policy #23338 issued to her father, Juan Rosario, Plaintiff v. NO.~~` Slip e~~~~ MAMSI INSURANCE RESOURCES, LLC, t/d/b/a MAMSI LIFE AND HEALTH INSURANCE COMPANY, Defendant 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 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 17013 (717) 249-3166 (800) 990-9108 69362 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA FRANCES M. ROSARIO, as named beneficiary under the Group Life Insurance Policy #23338 issued to her father, Juan Rosario, Plaintiff v. MAMSI INSURANCE RESOURCES, LLC, t/d/b/a MAMSI LIFE AND HEALTH INSURANCE COMPANY, Defendant CIVIL ACTION -LAW COMPLAINT AND NOW, comes Plaintiff, Frances M. Rosario, by and through her attorneys, Latsha Davis & Yohe, P.C., and brings this cause of action against Defendant MAMSI Life and Health Insurance Company, and avers the following: 1. The Plaintiff is Frances M. Rosario, an adult individual residing at 400 East Main Street, Mechanicsburg, Cumberland County, Pennsylvania. 2. Upon information and belief, the Defendant is MAMSI Insurance Resources, LLC, t/d/b/a MAMSI Life and Health Insurance Company (hereinafter "MAMSI"), a foreign corporation registered to do business in Pennsylvania with its main corporate offices at 4 Taft Court, Rockville, Maryland. 3. This matter involves a dispute regarding Plaintiff Rosario's entitlement to the proceeds of a life insurance policy issued by Defendant MAMSI as a group policy to Best Pontiac Olds Cad GMC ("Best"). 69362 4. Juan Rosario, Plaintiff Rosario's father, was employed by Best as an auto body repairman. Upon information and belief, his employment with Best commenced Apri16,1998. 5. Best paid premiums on Mr. Rosario's behalf as a participant in the Group Policy provided by Defendant MAMSI to Best for its employees. 6. Mr. Rosario designated his daughter, Plaintiff Rosario, as the beneficiary under the policy. See Exhibit "A", Certification of Coverage. 7. hi November of 1999, Mr. Rosario was diagnosed as suffering from lung cancer. 8. On or about June 8, 2000, doctors determined that Mr. Rosario's lung cancer had metastasized to his brain. 9. Mr. Rosario died on or about September 6, 2000. The official cause of death was listed as metastic squamous bronchogenic carcinoma. See Exhibit "B", copy of Death Certificate. 10. Mr. Rosario had met all eligibility requirements to be entitled to the benefits under the life insurance policy. 11. Some time after Mr. Rosario's death, Best notified MAMSI of Mr. Rosario's death. 12. On or about November 24, 2000, Defendant MAMSI forwarded a letter to Best indicating that "Juan Rosario is not eligible for coverage under [Best's] Group Life and Disability Policy." A copy of this letter is attached hereto as Exhibit "C". 69362 2 13. The Group Risk Assessment referred to in the November 24, 20001etter does not indicate that fulfillment of the active work requirement was a condition of coverage. See Exhibit "C". 14. The Group Risk Assessment contains neither definitions nor any other binding terms pertaining to eligibility. 15. At no time did Defendant MAMSI contact Plaintiff Rosario regarding her entitlement to the proceeds of the policy. 16. On or about June 25, 2001, Plaintiff Rosario obtained a copy of the policy in effect for the Year 2000. See Exhibit "D", Cover Letter and Policy. 17. Contrary to the denial letter of November 24, 2000, the policy clearly and unequivocally provides that "An insured may remain in an eligible class for a limited time if active full-time work ceases due to disability; leave of absence, layoff, or change to a part-time status." See Exhibit "D", Policy, p. 10 (emphasis in original). 18. On or about June 8, 2000, Mr. Rosario became totally disabled as a result of the cancer, which had progressed from his lung to his brain. 19. Mr. Rosario applied for and received Social Security benefits in the form of Supplemental Security Income. 20. Under the terms of the Group Life Insurance Policy, coverage would continue until "the end of the 12 policy month period that next follows the end of the policy month in which that person last worked as an active full-time employee. See Exhibit "D", Policy, p. 10 (emphasis in original). 69362 21. Under the terms of the Group Life Insurance Policy, coverage should have continued until at least June 30, 2001. 22. Mr. Rosario died within three months of the date of the onset of total disability, well before the expiration of the 12 month coverage period mandated in cases of disability. 23. To date, benefits have not been tendered by Defendant MAMSI to Plaintiff Rosario. 24. The amount of the death benefit was $10,000.00. 25. On or about August 10, 2001, the undersigned attorney sent a letter to Defendant MAMSI requesting payment of benefits within ten (10) days of the date of the letter. A copy of the August 10, 2001 letter is attached as Exhibit "E". As of August 31, 2001, no response has been received. COUNT I -Breach of Contract Plaintiff Rosario v. Defendant MAMSI 26. Plaintiff incorporates paragraphs 1 through 25 as if fully set forth herein. 27. As the designated beneficiary, Ms. Rosario is entitled to the proceeds of the Group Life Insurance Policy. 28. The Group Life and Disability Policy requires "Interest will be paid on proceeds not paid with 30 days after the death of the Insured. The rate will be declared by [MAMSI] but will never be less than 4% per annum." See Exhibit "D", Policy, p. 5 (emphasis in original). 69362 4 29. Plaintiff Rosario is entitled to interest on the proceeds in an amount not less than 4% per annum from the date MAMSI was informed of Mr. Rosario's death. 30. Defendant MAMSI's failure to pay the amounts due and owing to Plaintiff Rosario as more fully set forth above constitutes a breach of the Group Life Insurance Policy. WHEREFORE, Plaintiff Rosario requests that this Honorable Court enter judgment in her favor and against Defendant MAMSI in the amount of $10,000.00 plus interest as required by the Policy, an amount not to exceed $25,000.00, requiring compulsory arbitration in the County of Cumberland. COUNT II -Bad Faith Plaintiff Rosario v. Defendant MAMSI 31. Plaintiff incorporates paragraphs 1 through 30 as if fully set forth herein. 32. The language of the policy is clear and unequivocal that in the case of total disability, coverage would continue for at least an additiona112 months after the date of onset of disability. 33. Defendant MAMSI's assertion that Juan Rosario is not eligible for coverage under the Group Life and Disability Policy due to him not fulfilling active work requirements is in direct contravention to the clear and unequivocal language of the Policy mandating coverage for at least 12 months after the onset of the date of disability. 34. Defendant MAMSI's voiding of Juan Rosario's life insurance coverage demonstrates a reckless disregard for the rights of the insured. 69362 35. Defendant MAMSI's refusal to pay proceeds to Plaintiff Rosario on the basis stated in its November 24, 20001etter demonstrates a reckless disregard for the rights of the insured. 36. Defendant MAMSI's refusal to pay proceeds to Plaintiff Rosario is frivolous and unfounded. 37. Defendant MAMSI's refusal to provide benefits, as well as Defendant MAMSI's actions and omissions as more fully set forth above, constitutes bad faith under 42 C.S.A. § 8371. WHEREFORE, Plaintiff Rosario requests that this Honorable Court enter judgment in her favor and against Defendant MAMSI in the amount of $10,000.00 plus interest as required by the Policy, together with attorneys fees, court costs, interest and punitive damages to be calculated in accordance with 42 Pa.C.S.A. § 8371, an amount not to exceed $25,000.00, requiring compulsory arbitration in the County of Cumberland. Dated: 0 -~~ y' Respectfully Submitted, LATSHA DAMS & YORE, P.C. By: ~=~,D~ Steven M. Montresor Attorney LD. No. 74244 P.O. Box 825 Harrisburg, PA 17108 (717) 761-1880 Attorneys for Plaintiff, Frances M. Rosario 69362 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA FRANCES M. ROSARIO, as named beneficiary under the Group Life Insurance Policy of her father, Juan Rosario, Plaintiff v. NO. MAMSI INSURANCE RESOURCES, LLC, t/d/b/a MAMSI LIFE AND HEALTH INSURANCE COMPANY, Defendant CIVIL ACTION -LAW VERIFICATION I, Frances M. Rosario, hereby state that I am the Plaintiff in the within action and further verify that the facts set forth in this Complaint are true and correct to the best of my knowledge, information and belief; and acknowledge that the statements in said Complaint are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. DATE: / F/ rances M. Rosario 69362 CERTIFICATION OF COVERAGE Policyholder: Inf urad Person: Policy Number: Certificate Number: C rtificate Effective Date: Beneficiary: BEST PONTIAC-OLDS-CAD-GMC R05ARI0, JUAN 23338 582767267 Ol FEB 2000 FRANCES N ROSARIO Death Benefit: $10,000.00 (reduces to 65~ at age 65, - terminates at age 70.) Depen ent: $0.00 Suppl mental Death Benefit: $0.00 `r/~6 ~~ f@SI @nl q: ~, b This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as hotel ltegisrrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 / Local Registr r P 666913 No. aT 2000 Date .. xre] COMMONWEALTH OP PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH .ME •rLE NN4pER -.________ ---.-__ NA4 EGEVr e -a E„„ A ~uis ~RlT.-G P M a, rear) I oA~EDF UEn] D JU0.h S Y. 050.r10 RR ' A qiG 1• 1 ; ~ 1b - ~d~~ z ~ 6 [7O` nGE (lap 0+rwavl UnDEP YEAP VNLEP IOd DATE OF BIRTH erR]NPUCE:Cay ae4 CF GFRNrCh PlaC E ea P+yme--.a<.nsuv<I•msmemer yxl wNn Data MFPaa OaV'4er1 ilarea fnegnCWnllYl NOSPI)AL OTNE P; ~"'~ Y i n,,j (4} II lq 4~ ~ p Iro+r«.r ^ Ewawwnl iJ Dw ^ Nw~. ^ P.u.n<. ~ Q~MI t~ s. a. W i ] (A ' 4 CGJxrv OP pFjRN RH G E LI]Y,BOgD,1WPOf FACILRT HA Ills m qn gr ve NlMarc rwmmi M ivAS CECEOEM OF NISMNICORIGIN] ~Amerean lraran,&xa, wn.ra wc. RA E " 6 s awl ~u PA ~ 1e Sf Na ^ W. ~ X„.. Gap.n.~ M.ar~n. PUerla Rluw Me. IS ~ j n Y B .F_ . a n a. ~R un p. CFCEDENI'S USVAL E000PA]ION KI DGfR SINESYINOVSTPY W45 pECEDEM EVE IN DE EDEN EDUGTIpI 4APILnL STrIIV$-MameU SVPVIVING SPWSE (Give aaq tlwFCMVpnrrq d V.S. ARMEDFORCE$? cwn I Fl 5 C l4 « ver Mirtwa,WY Nabe aDrvwcaa (S UCM 111-tile .yv<ma9m ns+wl I.alrlrg xl :ap ral vse reln< l ' Ma^ ~~j emanlary ere arY E m 2 W`~, /I ~r,~ Vl. ]]N. Ia Fx Ix. 11_a 5•I N211 1]. b . 1 WW a ~<a~ IIVN 1]. DE{£pENT AILING AOOPF$ r C1y wrL 51Ye. Zp CWe1 DECEDENT'S lmai ) ^ Y y 1 // dyI S~ WOa,~~OIV K]~~ a EecaMM n ACTVAL 1)a. $lale pa 1 c. PESIDENCE 0ecebn ^P. ~'~j 1 ' 15re venrelms ~wN Ib NCeaen F•ea anomersEel pY I , if 1/j . xp~ I]4.Comry 1]a.IIU Mm acluYFmis of cM~h<o. FATNEp' AME IFirA,M .Ldzll MOTNy~ 5NA4E ifxsl. MgEk. Magen Surname) ,.- unn 'o ,,. hranci5ca loon G2 INFOP Ni'$NAME (]ypYPri'rll INF MANT'$MAILING AODRFS5151req.eMfEa4l .Zp LO]el 17 xq.. Wx• Ro 055 xpN. F s ~ H1 tiic A MET11000F q$P051T g N OTE OF DISPOSITION ptACE OF $PO$RXM.Neme NCemelery Gemalary L RKIN~OXYIbwe. 5N1e. ZN LMe 1 ~ 1 Burial ya Cremal'm^ Perra.al Fo-n$Ine^ DPr.1gn^ GM.5oacMx ^ IMmm, Oa yarlr1 '',^T^ G a(AxV or glove %ae((e C~ ~ ll ( ` ~ 1' 2 ]sa. xm. xlc. `C 1 J S,a. ~nR EOFfVNE LS vKE LICENSEE OR PERSON ACTING IS SVCX =CENSFyVM~ P EAxq ACOPES$OF FALI ltt // AA 1I ~ ~~~~~ Z2 ~~ ~ 1 ,- 0~ ~- lI ~` •= Y x/ Camp a mz 2Ja< rvMn unltyrrg e bIM IoI MyFmMlaage.M ur ea a11M m e . J a Ie an4 pace alalM I CENSE HVMOEP L M O.VE SIGNED Mysvcvn q niUda al lane of Ceara lO mm.)~~.a1a.al^ ie rE iA ISglrelu ~ I/ " ~ ~ (F1cnm.0aY `ta'I - i ~S 9 ~.. 2~ xb. ~ L, ~r x,< o ~ ~ Marv Sal6 mu,MCOmpelaaq prawrelaPamurceabalF TIME OF OEATM DATE PPON LACED DEAD IMpnm.Oay Yeerl WAS CASE PEFEPPED IO MEDICAL EFAMINEPuCIXiONEP] - . ~/ ' ~ ~ n. ^ m U O u ~ 2 / - M. x.. , ~ xs. za $]. NPTK E1rlerlM Eiseases. rnjurteigcDmpKarpv..nitFpuzealM Oeam MMl anlBr lira nrMeOl pymq. ir2xas<alai or esprralory ar ezl.]KKkOr Marl laAVre 1ApPparm a PAIR X: QIw15gnXr<]M MFazsmrrlrANiy lP Cealn, bA Lm Pnh om cavae an eau, Fns 1 rv naunuwmme urel«Mm u.rs. eve^x.PUiT I. a,+i.1 IYYEg4iE CAV5E1Frny r ~ 1 M m v /y ¢ <~ d:~.o-Gargxim a ~j,~2/ 'GVr-ca'G(~ r Fpm Eaaml-~ DuE roICR AS ACONSEOVEn Ft: ' Sepwnll.M Fa mrwnmia ~~ ~ Xarry, baNnq lPimmeaule OVE ]OICN A54CGNSEOVENCE CFl: i cwrs.EMx IMDEflLYING OUSE (gseaaa~nNry c 1 ve..4gaE <.N.u ov$roIDR AS ncansEa]ENCE OFI: ra,.agnE,amlus] a M SAN AV]OPSY WERE AUTOPSY FINDINGS ANNER OF DEATH DATE DFINJVRY LIME OF INJUPY INIVPY Ai'MJgK) CESCRIBE MbN INJVPY OCCVRRED PEPFOR4ED] AMIUBLE PP1OR 10 IMmm, Day, Rarl COMPLETION 6CAUSE I~ ^ N m~g rJ H OF OERN] o a arurel Y ^ ~^ Ac<genl ^ PeMrrg inwil9alun ^ ea ^ O ^ ]14. JpO. ]lt. ba. M w. N.^ Yea ^ N, ^ coup relMael..mrr,.a 5.zw PucE OF INIDPY.P m., farm. r<.1.MaPY. anq. LOCRKxN rsxXM.cMxE.n.sMl.l ly WrMrq. elc ISpsrlvl iM, xae. ]Oa. ]M. CEI<i1FlEP ICI`xFpny mel $pNRU TITLE OF CEPi1F P 'CFPTIFYING PXYSICIAX fPFrycyncerlMmq Uxse J Eeam vner anaPe~ p~vttan lrai Pcv+rcM Marn aw cwnaelM Ilem }]I I^~ TeW peal elmY krgeekE9e. Eeallr occunad ax<n1M<au<e(all^a manner as alelM ....................... ... .... ..... .. ~J f ]IO LI E MBER GATE SJGNED IMmm Day 4arl 'PRONGVNCINC ANOCERi1FY1NE PNYSICIAN IPnyuan Mir yar.wrtm 9ueallr aracennr~~q locavx olEearnl Fyt OG. Ct (-d=-F \ i/ / Te IM Fenelmy4na~lee e.a<aln ttc.rr<Gal R Ne nm<.ml<. and PL<e. aria au.mlM<ar,xl•1 ••a manner as .rn<a........_.... ^ ] I 1' O ]0.J f0 NAME AND AGGRESS OF PERSON WNO COMPLETED cAU f OF OEATM (llem $]] TYpe P Prinl 'MEDICAL E%AMINEP/CORONEP On IN<eP f emineiiOn C/ - vezlrgal nmYOpin~on,a voce al In Ime Gale ane pl ne DUe la lne cause(s) aria ^ menneya eE .. .... ........ ...... ...... ..... ... ...... ]1r. ]x REGiSTReR'S SIGrv/AT/U~RE/~//~ DN~VM}BEAR //{-/r~ // 0 I -~Nn%1/ _,r l / / ofl. ~?Y ~ ORE L4EOIMOnm /(Q~ rte l/ va. / /Yr r 7 -I ~, r. ~ November 24, 2000 Best Pontiac-Olds-Cad-GMC Attn: Charles Beans, Controller 100 );isenhower Drive PO Box 74 Hanover, PA 17331 RE: .Juan Rosario -~ MAMSI Life and Health Insurance Company (NiLH) Member - M582767267*Ol Dear Mr. Beans: It has come to the attention of MAMSI Life and Health Insurance Company (MLH) that Juan Rosario is not eligible for coverage under your Group Life and Disability Policy. Please refer to page 1, #1 of your Group Risk Assessment, it states, "Full-time is defined to be employees working a minimum of 35 hours per week on a regular year-round basis." Information provided by your company shows that Juan Rosario's last day of work was June 7, 2000. At this time MAMSI Life and health Insurance Company (MLI-I) is voiding Mr. Rosazio's Life and Disability Coverage due to him not fulfilling the Active Work Requirements. If you have any questions please call me at (301) 360-8703. Sincerely, By; Gary Therkildsen Director Special Investigations MAMSI Life and Health Insurance Company (ML}-I) cc: Mark Biancucci, Group Services Kathleen Graham, Customer Support Suzanne Mayhew, Life and Disability DU.It.,~ ~~th . Drc~{Gr~rk. (4tu,~4.,n~1_~7a> • I Ru~1-s~i~,_,;~-{~ • ~;~~4) ~hn_`:nv; • {'.~~~ (3n 41 3on_R`nu Cur~~~n at, aJJrr~c-l-Ldl llnn~ IL~a kcib;, M.v~-Iaui 'I ~R.ri11 ~ . ~~-~~~~~~. n ~a i u~i rn m Application is hereby made for giaap covsraga: joy::iliglb/e efaployves and tha r e!lgibts depsndeti~s bacad on cha /o!lowing information: Company Namet Address d~; ....~Pd; `~~~~x ~~ ,:., city: l~An~01!ER si.«r>z~p-cate'::, lr!'~~,~ .:': Ctrmpany OfReial: R(d•8S$/~_ L: •;yll~P~rz } ~'k. ~rid~, Perron m Conucr: ~NAR~~S'IQ~-QEA:+J6 'Tldea.~ Nature aE 8mineast Total No. of Ecttployeeu ~_Ier ~Fu~l!/-rtlyinet=,~Ld;~ Pats-time:.~1." ' U Tool number of eligible employes:;:"' " "~ ~" '~" :, ~A~iunber enrolled: ~ .. . 1. Full•ame is defined to be em~loyse~woeking ~miriiinum of~~/~• hourajoec.week 2. Average number of Eu1l-tlma'cmployees foi the put two years:.:L~,. 3. Are union employeer covered by itnother plan? . ; .N~" 4. Are 3096, or more, of youc employees farnlly mtunber^J " Whsc i^ ehe average age of the enrolled employeesT ~~" Rrgue~ted.effectiva date: Are alt eligible employee octivaly.atworbtt_ Do you have any employee age 63 Drover aetlv~ty"[twotkj;,,. :~~ NOT& Veci[iutioa e(smf>foymandpmmlw.o(hgputp I^ rpoired foralf rmpbyrcp.ap eS or ovrr.: COMPANY WAI7'NG PPRIUD: ~ 17'hir is the pmtnmt of rims m empluyrr mutt brert Employer premium eonvibudon to: Employee wverage:~9fo;': Dependent eoveeig~ NOTPa 1t it greed rh.r U rhr patployrr peyr the eedra cort'of 16t,ww~Wr[[pQe ~ 100% of the dlalbie empley.p mVtt g. nuk. roontLty pgto0 dedoatom for thp.ahploret contn6oaonr, U asy, far"raeh ampMyee mroWn~ !e the Are there any current or prior employers dr dependents tioveied under COBRA? [f YES, how manyl ipbra•tndlau on~implom eppllatlonl Do you have any employee or any knorVhidge of employee' dependents who live out of the area end wha require.heaithtwera~et if YES, number of employees of dtpendents .nd where they are locoed: th ~b'veYS~~tfn:tlie'pi1i:2 yant';'. , _ . , . .. _.. _... ..1.1;:.'.. .. lephotiee "~7/7~6=`7-31/ NA _--.~... ^ regular year-round basis. ^ YPS CJ NO ^Yes Giro ~ES Q NO [~StES [~ NO b~fote Delna dlaiblo for benefin.l _ ~ 9'e empfoyrt sarvcr to ®Y~ C>9~o ,AYES (~f0 . ~: ~~ j J ' ,, M.' - ;7~;i1 ... ... "~.~.5 ~..\~: ,wx z s ~ OPTiMU~\q MAMSj ALL(A:VCE M.D.IPA CHOfCE~, ,,,,,,,~, _ ~„ PPO June 25, 2001 Steven M. Montresor, Esq. Latsha. Davis & Yohe. P.C. FG Box 825 II.?n'isburg, PA 1710°-0825 RE:.Juan Rosario, Sr. NIAMSI Member 1`v`o.: M582767267x01 ~' o-ar File No.: 344-O1 D:'ar y[r. ~~[or~tre.>or: As requested in ycur letter o: June 20, 2001, please find enclosed the Group Life and Disabiiity policy for E3est Pontiac-Olds-Cad-GMC, Group #2,338. This policy was in effect for the calendar year 2000. Should you have any questions or neec', additional information, please contact me at (;01)360-8703. Sincerely, n Lary Therkildsen Director, Special Investigations MAMSl Life and Healt.".Insurance Company(MLH) PO. Sos 93~ ^ Frederick, Maryland 21705 • Fax: (301) 360-897] Corpo„ue address: -4 Taft Court = Rockv=.lie, Marcland 20850 uww_mainsi.com Group Life Insurance Policy This policy is anon-participating policy Rockville, MD Form 100 GL (PA) Life and Health Insurance Company TABLE O]F CONTENTS MAJOR SECTIONS DEFINITIONS ................................................ 1 GENERAL PROVISIONS .......................................... 3 DEATH BENEFIT .............................................. 5 .................................................. PREMIUMS 5 CONVERSION OPTION .......................................... 7 ELIGIBILITY AND EFFECTIVE DATE .............................. 9 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS ................. 12 SHORT TERM DISABILITY BENEFITS ............................... 14 Form 100GL(PA) i DEFINITIONS The following terms which appear in bold italics throughout the Policy have special meaning. Active, Full-time An active employee performs all of the duties of a job with the Employee employer covered under this Policy. This job may be at either the employer's normal place of employment or at another place to which the regular business operations of the employer required the employee to go. To be full-time, an employee must work for an employer covered under this Policy, at least 30 hours each week and on the regular payroll r of the employer for that work. An active and full-time employee, as defined above, may also include members of an association or employees of member firms of an association to which the Policy is issued. Insured means the person whose life is insured. Period of Total This is the period of time that a person is totally disabled. New periods Disability due to the same or related causes must be separated by return to active work for 30 consecutive days or more. Periods due to different causes must be separated by a return to active work for at least one day. No new waiting period will be applied if there are 30 or fewer days between periods of disability. Partial Disability means as results of the sickness or injury which caused total disability, the Insured is: 'unable to perform one or more, but not all, of the material and substantial duties of any other occupation on a full time or part time basis; z able to perform all of the material and substantial duties of any occupation on a part time basis. Partially Disabled see Partial Disability Policyholder means the corporation, association, partnership or proprietorship that purchased this plan of group insurance. Service Waiting This is the period of time, set forth in the application that the proposed Period insured is not eligible for coverage under this Policy. Form 100GL(PA) 1 Total Disability means unable to perform the main duties of the Insured's occupation. After the first continuous year, the Insured must be unable to perform the duties of any occupation for which the Insured is qualified by education, training or experience and is not engaged in gainful employment. Totally Disabled see Total Disability. Waiting Period The period of consecutive days of total disability for which no benefit is payable. The waiting period begins on the first day of total disability occurring after the effective date of coverage. We, US, Our refers to MAMSI Life and Health Insurance Company. Form IOOGL(PA) 2 GENERAL PROVISIONS The Contract The Policy, the master application and the enrollment applications will constitute the entire contract. A copy of any application of the policyowner shall be attached to the policy when issued. Any statements made by the Policyholder or the Insured are considered representations and not warranties. Authority to No agent or other person has the authority to modify or change the Modify provisions of this Policy except by an agreement in writing signed by our president, our vice president or our secretary and the Policyholder. Certi6Cate5 We will issue to the Policyholder for delivery to each Iusured, an individual certificate. The Insured is the Certificateholder unless otherwise specified. It will summarize the benefits of the Policy, to whom the benefits are payable and the rights of the Certificateholder when the coverage ends. The Certificate is not a part of the Policy. It does not modify any of the conditions or provisions of the Policy. Group Policy A copy of the Policy is at the office of the Policyholder. It is available InspeCtiori for inspection by covered persons during regular business hours. Ownership of The Policyholder is the owner of the Policy and may request changes or Policy an amendment to the Policy without the consent of the Insured, any assignee or beneficiaries. However, no change may affect the Insured's right to change the beneficiary or the right to exercise the conversion privilege. Essential Data The Policyholder will keep a record of the insured persons. This record will contain all of the data specified by us. Reports from this data will be furnished as needed for administering terms of the Policy and to determine premiums rates. Incontestability The Policy cannot be contested by us, after it has been in force during the lifetime of the Iusured for two (2) years from the effective date, except for nonpayment of premiums. No statement made by any person insured under the Policy relating to the Insured's insurability shall be Form 100GL(PA) 3 used in contesting the validity of the insurance after such insurance has been in force for two (2) years during the Insured's lifetime unless such statement is contained in a written instrument signed by the Insured and a copy has been furnished to the Insured, his beneficiary or his personal representative. Misstatement If the Insured's age, sex or any other essential data has been misstated, an equitable adjustment shall be made in the premiums or the amount of insurance. Any premium due will be based on the correct amount of insurance or rate. We will rely only on the data furnished by the Policyholder in making corrections. Beneficiary The Insured has the right to designate the beneficiary. This designation may be changed by the Insured any time unless it is a designation specifically stated to be irrevocable. Changing an irrevocable beneficiary will require the signature of the irrevocable beneficiary. The Policyholder may never be a designated beneficiary. The designation must be made in written form that is acceptable to us. The change will be effective on the date it is signed once it is recorded in the home office. Two or more named beneficiaries will share equally in the proceeds unless otherwise specified. If any beneficiary dies before the Insured, the rights and interest of such beneficiary will automatically terminate. Only those beneficiaries who survive the Insured are eligible to share in the proceeds. If no beneficiary survives the Insured, we will pay the proceeds to the Insured's estate. Assignment The rights and proceeds may be assigned by the Insured. The assignment must be made in writing on a form acceptable to us. It must be an absolute assignment that transfers all rights of the Insured under the Policy, except those of an irrevocable beneficiary. The assignment may be made to one or more of the following relatives of the Insured: a spouse, children, parents or siblings. It may also be made to the trustee of a trust for one or more of those relatives. We are not responsible for the validity or results of the assignment. Form 100GL(PA) ¢ No benefit will be paid for any loss that results from or is caused EXCIuSIOriS directly, indirectly, wholly or partly by: • intentional self-injury, suicide or attempted suicide, while sane; • a war or act of war; DEATH BENEFIT Payment of Upon receipt of proof of the death of the Insured, we will pay to the Proceeds designated beneficiary the amount of insurance shown in the Schedule of Benefits. Interest will be paid on proceeds not paid within 30 days after the death of the Insured. The rate will be declared by us, but will never be less than 4% per annum. If due proof of death is submitted to us more than 180 days following the date of death of the Insured, interest shall accumulate and be payable from the date the proof is submitted, to the date the policy proceeds are paid. Benefits will be paid in a single lump sum unless a settlement option is chosen during the life time of Insured.. FaClllty Of If there is no surviving named beneficiary, we may use our judgment Payment and pay up to $250.00 of the proceeds in total to a person(s) appearing to have incurred expenses in connection with a fatal illness or for the burial of the Insured. Any payment made in good faith, fully discharges us to the extent of the payment. Spendthrift Clause To the extent allowed by law, no benefit of the Policy is subject to the claim or legal process of a creditor of an Insured or a beneficiary. PREMIUMS When to Pay The first premium is due as of the effective date, and is payable in advance. All premiums after the first premium are payable on or before the date they are due and must be received by us in our home office. A receipt will be available upon request. Grace Period This Policy allows a grace period of 31 days for premium payments except the first. Premiums not paid on or before the due date, may be paid during the 31-day period immediately following the due date. Coverage will continue during the grace period. Form 100GL(PA) g If the premium is not paid by the end of the grace period, all coverage will terminate. Continued Premiums due for an Insured who becomes totally disabled will be Coverage Without waived. Coverage will continue to be in force during the period of total Payment disability if: • the Insured ceases to be in an eligible class; • the disability starts while the person is insured under this policy and under age 60; • the disability has been continuous for at least nine (9) months; and • we approve the Insured as totally disabled. The amount of insurance is the amount that the Insured was eligible for at the start of the disability. The amount will reduce at the ages shown in the Application and terminate at retirement as if the person were not disabled. Proof of Disability Written notice and the first proof of total disability must be received by our Home Office within 12 months from the start of the period of total disability. Proof of continued total disability must be given as often as we deem necessary within 90 days of the date of request. After the first two years of total disability, proof will not be required more than once a year. We may require an examination at our expense made by a physician approved by us. Termination of This Policy will terminate on the date of one of following events: The Policy • the date the grace period expires for nonpayment of sufficient premium; or • the date the Policyholder requests termination of the policy. Termination of the Policy will not end coverage for an Insured that is totally disabled. Coverage will continue until the earliest of: • the end of a period of total disability. Form 100GL(PA) 6 • the date the Insured ceases to be totally disabled • failure to provide written proof of continued total disability within the time required. Termination of The coverage on the Insured will terminate on the earliest of: Coverage • the date the Insured ceases to be a member of an eligible class; • the date the Insured's eligible class is eliminated; • the date the Policy is terminated; • the date premiums remain unpaid at the end of the grace period; • the date the Insured requests termination of coverage; • the date the Insured's employment or group membership terminates; • the date the Iusured dies. CONVERSION OPTION Conversion Rights If the Insured's insurance coverage ends because of termination of group membership/employment or membership in the class or classes eligible for coverage under the policy, all or part of the amount of insurance that ceases may be converted to an individual policy of life insurance. If the policy terminates, or there is an amendment of the policy to terminate the Insured's eligible class, or an amendment to reduce the amount of insurance available in the Insured's eligible class, and the Insured has been covered under the Policy for at least five years, coverage may be converted for an amount not more than the smaller of: • $10,000.00; or • the amount of the terminated insurance less the amount any life insurance for which the Insured becomes eligible under any other group policy within 31 days; provided that any amounts of insurance that shall have matured prior to termination are not included in the Form 100GL(PA) 7 amount of terminated insurance. Conversion Policy The conversion policy will be any type of individual life insurance policy, other than term life insurance, then being issued by us. The conversion policy will not include accidental death, disability or other supplementary benefits. It will be issued without evidence of insurability. The premiums for the conversion policy will be at our usual rate for its type and amount, the Insured's class of risk and the Insured age on the last birthday of its effective date. To exercise the conversion option, the Insured must submit a written application and the first premium payment within the conversion period. The conversion period is the 31 days immediately following termination of all or part of coverage. The policy will take effect at the end of the conversion period. Death During the If the Insured dies during the conversion period, the amount of life Conversion Period insurance that would have been converted to an individual policy shall be payable under the group policy whether or not the application for the individual policy or payment of the first premium has been made. Form 100GL(PA) $ ELIGIBILITY AND EFFECTIVE DATE Ellgiblllty Eligibility for coverage under this Policy will be effective from the First Requirements day that, as shown in the application, the proposed insured: • is affiliated with the Podicyholder as an employee or group member; • is in an eligible classes; and • completes the service waiting period. No corporate officer or director will be eligible solely due to title. A partner or a sole proprietor will not be eligible solely due to position. If the proposed insured requests coverage above the maximum amount specified in the application, the Evidence of Insurability Requirement must be met. The proposed insured must be an active full-time employee to be eligible. There will be no multiple coverage for insured who are associated with more than one group covered under the same group policy. Eligibility of a member or employee of a covered group will be decided by the Policyholder. The total hours worked by an employee for all covered groups will be used in figuring full-time employee status. The service waitiug period of a former employee whose employment was involuntarily terminated and who is rehired will be reduced if rehired within one year of termination or ceased work due to entry into the armed forces and returns to work in the time prescribed by law. In such a case, the employees period of service before leaving work will be credited toward the present service waiting period. Active Work An employee must be at active work for new coverage to take effect. Requirement Active work is work preformed an active, full-time employee. The employee will be considered at active work on a regularly scheduled non-working day if the employee is not then disabled and could have been engaged in active work had it been a work day and was engaged in active work on the last preceding regular work day. Form 100GG(PA) 9 If the employee is not at active work on the date that coverage is to take effect, the effective date will be deferred until the first day that the employee is at active work and meets all other requirements need to affect the coverage. Evidence Of When evidence of insurability is a condition for coverage, it must be in Insurability a form set by us. All evidence required to evaluate the proposed Requirement insured as an acceptable risk must be given to us. The requirement will be met on the date we accept the evidence. Enrollment A proposed insured must enroll for coverage that is shown to be Requirement contributory in the application for it to become effective. Coverage is contributory when the Insnred must pay all or part of its premium. Enrollment is making written request for coverage on a form acceptable to us. The form may include a payroll deduction authorization that allows for the deduction of any required premium contributions from the employee's wages. The enrollment form must be completed and signed by the proposed insured. EffeCtlve-Date Coverage will be effective on the first day of the policy month that coincides with or next follows the date the following requirements are met: • the Eligibility Requirement • the Active Work requirement • the Evidence of Insurability Requirement • the Enrollment Requirement. COIltlnuatlOri This provision applies to all coverage other than weekly income benefits During NOn- that may be a part of the plan. An Insured may remain in the eligible Working Periods class for a limited time if active full-time work ceases due to disability; leave of absence, layoff, or change to a part-time status. however, this continuance will be on the earliest of these times: • the date that the Insured's continuance in the eligible class is ended by the Policyholder. The date must be set in a way that all employees are treated the same; • for disability, the end of the 12 policy month period that next follows the end of the policy month in which that person last worked as an active full-time employee; Form 100GL(PA) 10 Form 100GL(PA) • for leave of absence, layoff or change to part-time status, the end of the policy month period that next follows the end of the policy month in which the Insured last work as an active full-time employee. However, this continuance will not apply to an Insured who is entering the armed forces of any country. While the Insured is being continued in an eligible class as stipulated above, insurance benefits will be based on the benefits of that Insured's eligible class on the last day of active, full-time work and are subject to the reductions in benefits of the Insured's eligible class. 11 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Benefit Payable If an Insured suffers a covered loss, other than loss of life, because of an injury caused by an accident, the loss must occur within 90 days after the date of the accident. Notice of the loss must be received by us within 30 days after the start of the covered loss. We will pay the benefit amount when we receive proof, satisfactory to us, of the covered loss, other than loss of life within 90 days of the date of the loss. A covered loss means: • loss of a hand by severance of four entire fingers; • loss of a foot by severance at or above the ankle; • total and permanent loss of sight. Benefit Amounts We will pay the full benefit amount as shown in the Schedule of Benefits for loss of: • life; • sight in both eyes; • both hands; • both feet; or • any combination of foot, hand or sight of one eye. We will pay one half the benefit amount as shown in the Schedule of Benefits for loss of: • sight of one eye; • one hand; or • one foot. We will not pay more than full benefit amount shown in the Schedule of Benefits for all losses due to the same accident. Form 100GL(PA) 12 Payment Options Payment options may be elected for loss of life or dismemberment benefits in place of one sum payment. The options that are available are those offered by us at the time of election. Elections must be written in a form approved by us and received at our home office. Claims will be paid not more than 60 days after we received written proof of loss. The Insured may elect dre payment option. That election may not be revoked after the Insured's death. If the Insured dies without choosing a payment option, the beneficiary may elect the payment option. The payee must be a natural person who takes the benefit in to his or her own right. Exclusions No benefit will be paid for any loss that results from or is caused directly, indirectly, wholly or partly by: • intentional self-injury, suicide or attempted suicide, while sane or insane; • bacterial infection, unless the infection results from an accidental bodily injury; • a physical or mental sickness or treatment of that sickness; • voluntary intake of poison except accidental food poisoning, drugs, gas or fumes except in the course of employment; • a war or act of war; • disease of any kind, and any treatment of such disease; • participation in a riot or other civil disorder • an attempt to commit, or committing felony or an assault (except in self defense); • flight in an aircraft or spacecraft, or descent from such a craft while in flight, or subsequently drowning, if the insured is a pilot or officer or crew of the craft, is giving or receiving aviation training, has duties relating to the craft or is being flown for the purposes of descent from the aircraft. • being legally intoxicated as defined by the law in the state in which the policy is delivered or under the influence of any drug unless it was prescribed for the Insured by a doctor. Form 100GL(PA) 13 SHORT TERM DISABILITY BENEFITS The benefits described in this section are optional. If elected, the Weekly Benefit, Maximum Number of Weeks Payable and Waiting Period referred to in this section are specified under Schedule of Benefits in the application. Short Term If the Insured becomes totally disabled while insured under this policy, Disability Benefit we will pay benefits during the period of total disability at the rate of the Weekly Benefit per week, not to exceed the Maximum Number of Weeks Payable, for any one period of total disability. The Insured must provide proof that the disability is due to anon-occupational sickness or injury and that the regular attendance of a physician is required. Proof must be sent within 30 days after the waiting period. Benefits will begin after the expiration of the waiting period, if any. Duration Of Weekly benefits will be paid up to maximum benefit period. The benefits Benefits will end on the earliest of: • failure to submit required proof of continuing total disability; • the date total disability ends; or • the date the maximum benefit period ends. Successive periods of total disability separated by less than two weeks of active work, on a full time basis shall be considered one period of total disability unless the subsequent period of total disability is due to injuries or sickness entirely unrelated to the causes of the previous disability and commences after return to active work on a full time basis. If coverage under this Policy ends while the Insured is totally disabled, payment under this benefit will continue as if coverage was still in force under the Policy, for that disability only. No benefit will be paid for a disability that results from or is caused Exclusions directly, indirectly, wholly or partly by: • a mental disorder, chronic alcoholism or drug dependency, except while confined as a bed patient in a medical care facility; Form t00GL(PA) 14 • intentional self-injury, suicide or attempted suicide while sane or insane; Form 100GL(PA) • participation in a riot or other civil disorder • a war or act of war Benefit will not be -paid for a disability when the Insured: • ' is not under the regular care of a physician; • performs any work for pay or profit; or • is receiving benefits under workers' compensation or similar law 15 +~Gary A. Therkildsen, Director August 10, 2001 °Page 2 bad faith statute provides for interest, punitive damages, court costs, and attorneys' fees against the insurer at the discretion of the court if the court finds the insurer acted in bad faith. Thank you for your attention to this matter. Sincerely, ~~ Steven . Montresor "~. c. - ~_ i © ~^ ti c ` ~ `~ ~ _. ~ ~ _ ~i~ ~ o v~ ~ \~ `~ _:a ~ ~ i ti ~~' 3 0 `~-- FRANCES M. ROSARIO, Plaintiff v. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW MAMSI INSURANCE RESOURCES, LLC, t/d/b/a MAMSI LIFE AND HEALTH INSURANCE COMPANY, Defendant. No. 01-5198 PRHFC`TDF FOR EN'~'R`~ OF APPEARANCE TO: Curt Long, Prothonotary Please enter the appearance of Keefer Wood Allen & Rahal, LLP by Charles W. Rubendall II and Donald M. Lewis III on behalf of defendant, reserving its right to respond to plaintiff's complaint pursuant to the Pennsylvania Rules of Civil Procedure. A single copy of all items sent by your office to the attention of Mr. Rubendall alone will be satisfactory. Dated: September 20, 2001 KEEFER WOOD ALLE(N/&~RAHAL, LLP j ~'.-'Y. y~+ By ~ ~ i"L Charles W. Rubendall II I.D. # 23172 Donald M. Lewis III I.D. # 58510 210 Walnut Street P. 0. Box 11963 Harrisburg, PA 17108-1963 717-255-8010 and 255-8038 Attorneys for defendant I, Charles W. Rubendall II, Esquire, one of the attorneys for defendant, hereby certify that I have served the foregoing paper upon counsel of record this date by depositing a true and correct copy of the same in the United States mail, first-class postage prepaid, addressed as follows: Steven M. Montresor, Esquire Latsha Davis & Yohe, P.C. P. O. Box 825 Harrisburg, PA 17108 KEEFER WOOD ALLEN & RAHAL, LLP By ~ ~' ' t~~~ Charles W. Rubendall II Dated: September 20, 2001 C7 e: ~~ __ _~ r::: - ~ - ~- o - cn __.. - ~-i -;_„ ~'L ::~ ~, -/ Ti ~ (~ F , t , FRANCES M. ROSARIO, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. MAMSI INSURANCE RESOURCES, LLC, t/d/b/a MAMSI LIFE AND HEALTH INSURANCE COMPANY, Defendant No. 01-5198 CIVIL Civil Action - Law NOTICE OF REMOVAL OF ACTION TO THE UNITED 3TATE5 DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA C') C -c~; ~~ ,._. TO: THE PROTHONOTARY OF THE COURT OF COMMON PLEAS _~:. n c7 J:. » m t „7, _ -and- -~:_, Vic. , , .,, Plaintiff's counsel of record: ~-- ~ _~ ~-" ~ Steven M. Montresor, Esquire ~>~~ ,~, "n ~ Latsha Davis & Yohe, P.C. -r_ ~ `c- ~ ~ P.O. Box 825 - <p Harrisburg, PA 17108-0825 In compliance with 28 U.S.C. ~ 1446(d), you are hereby notified of the filing of a notice of removal of this action to the United States District Court for the Middle District of Pennsylvania. A copy of the notice of removal is attached as Exhibit 1. KEEFER WOOD ALLEN & RAHAL, LLP By: (/ Charle~'W. Rubendall II Attorney I.D. #23172 Donald M. Lewis III Attorney I.D. #58510 210 Walnut Street P.O. Box 11963 Harrisburg, PA 17108-1963 (717) 255-8010 and -8038 Date: September ~, 2001 Attorneys for defendant MAMSI Insurance Resources, LLC, t/d/b/a MAMSI Life and Health Insurance Company IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA FRANCES M. ROSARIO, Plaintiff v. MAMSI INSURANCE RESOURCES, LLC, t/d/b/a MAMSI LIFE AND HEALTH INSURANCE COMPANY, Defendant :® . ~ V CASE NO. NOTICE OF REMOVAL c~o~~ ~.®~,' FILF~ HARRISBURG, PA ~~P 2 ~~ 2Q01 tv~ARY @, R'ANDREA, ~; , ;~ Defendant MAMSI INSURANCE RESOURCES, LLC, t/d/b9~'~,IFE ~c7utq .c. , AND HEALTH INSURANCE COMPANY ("MAMSI"), by its counsel, Keefer Wood Allen & Rahal, LLP, hereby files its notice of removal of this action to this Court and states as follows: 1. MAMSI is named as a defendant in Civil Action No. Ol- 5198 in the Cumberland County, Pennsylvania, Court of Common Pleas (the "State Court Action"). 2. The Complaint in the State Court Action was filed with the Prothonotary of the Court of Common Pleas of Cumberland County, Pennsylvania on August 31, 2001. MAMSI was served with the complaint by certified mail, postmarked on or about August 31, 2001. 3. This notice is being filed within thirty (30) days after defendant received a copy of plaintiff's initial pleading setting forth the claims for relief upon which plaintiff's action is based. 4. Copies of all process, pleadings, and orders served upon the defendant in the State Court Action are attached hereto as Exhibit A. 5. The claims for relief alleged against MAMSI in the State Court Action arise under, and are governed by, the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001 et sea., for the following reasons, among others that appear on the face of the complaint and/or the exhibits attached thereto: a. Plaintiff's allegations relate to an employee welfare benefit plan, namely, a group insurance plan -- established by Best Pontiac Olds Cad GMC ("Best") to provide a program of life insurance, accidental death and dismemberment, and short term disability benefits to its employees, including plaintiff's decedent, Mr. Rosario (see complaint, ¶¶3-4, and exhibits A, C and D thereto); -2- b. The class of beneficiaries is ascertainable as full- time employees of Best working at least 35 hours per week on a regular year-round basis (see exhibits C and D to complaint); c. The employer "paid premiums on Mr. Rosario's behalf as a participant in the Group Policy provided by [defendant] to Best for its employees" (complaint, ¶5); and d. The plan established procedures for receiving benefits (see exhibit D to complaint). Accordingly, this Court has original subject matter jurisdiction over this action pursuant to 28 U.S.C. § 1331 and 29 U.S.C. § 1144. 6. This action may properly be removed to this United States District Court pursuant to 28 U.S.C. § 1441(b). 7. This action was commenced within the judicial district and division of the United States District Court for the Middle District of Pennsylvania. 28 U.S.C. § 1441(a). 8. Promptly after the filing of this notice of removal, MAMSI shall give written notice of the removal to the plaintiff through her attorney of record in the State Court Action and to -3- the Prothonotary of the Court of Common Pleas of Cumberland County, Pennsylvania, as required by 28 U.S.C. § 1446(d). KEEFER WOOD ALLEN & RAHAL, LLP By : ~-~ G ,~va~- ~ Charles i~ Rubendall I I Attorney I.D. #23172 Donald M. Lewis III Attorney I.D. #58510 210 Walnut Street P.O. Box 11963 Harrisburg, PA 17108-1963 (717) 255-8010 and -8038 Date: September ~, 2001 Attorneys for defendant MAMSI Insurance Resources, LLC, t/d/b/a MAMSI Life and Health Insurance Company -4- )~ ~i, . - , ~ r IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA FRANCES M. ROSARIO, as named beneficiary under the Group Life Insurance Policy #23338 issued to her father, Juan Rosario, Plaintiff v. MAMSI INSURANCE RESOURCES, LLC, t/d/b/a MAMSI LIFE AND HEALTH INSURANCE COMPANY, Defendant NOTICE CIVIL ACTION -LAW 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 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 Baz Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 „~ r, .. -, .. :_:.. ~T.i _ i r/ `/ ~-_- 31' IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA FRANCES M. ROSARIO, as named beneficiary under the Group Life Insurance Policy #23338 issued to her father, Juan Rosario, Plaintiff v. NO. MAMSI INSURANCE RESOURCES, LLC, t/d/b/a MAMSI LIFE AND HEALTH INSURANCE COMPANY, Defendant CIVIL ACTION -LAW COMPLAINT AND NOW, comes Plaintiff, Frances M. Rosario, by and through her attorneys, Latsha Davis & Yohe, P.C., and brings this cause of action against Defendant MAMSI Life and Health Insurance Company, and avers the following: The Plaintiff is Frances M. Rosario, an adult individual residing at 400 East Main Street, Nfechanicsburg, Cumberland County, Pennsylvania. 2. Upon information and belief, the Defendant is MAMSI Insurance Resources, LLC, t/d/b/a MAMSI Life and Health Insurance Company (hereinafter "MAMSI"), a foreign corporation registered to do business in Pennsylvania with its main corporate offices at 4 Taft Court, Rockville, Maryland. 3. This matter involves a dispute regarding Plaintiff Rosario's entitlement to the proceeds of a life insurance policy issued by Defendant MAMSI as a group policy to 13cst 1'c>ntiac Olds Cad GN1C ("Best") l~ 4. Juan Rosario, Plaintiff Rosazio's father, was employed by Best as an auto body repairman. Upon information and belief, his employment with Best commenced Apri16,1998. 5. Best paid premiums on Mr. Rosazio's behalf as a participant in the Group Policy provided by Defendant MAMSI to Best for its employees. 6. Mr. Rosario designated his daughter, Plaintiff Rosario, as the beneficiary under the policy. See Exhibit "A", Certification of Coverage. 7. In November of 1999, Mr. Rosario was diagnosed as suffering from lung cancer. 8. On or about June 8, 2000, doctors determined that Mr. Rosario's lung cancer had metastasized to his brain. 9. Mr. Rosario died on or about September 6, 2000. The official cause of death was listed as metastic squamous bronchogenic carcinoma. See Exhibit "B", copy of Death Certificate. 10. Mr. Rosario had met all eligibility requirements to be entitled to the benefits under the life insurance policy. 11. Some time after Mr. Rosazio's death, Best notified MAMSI of Mr. Rosario s death. 12. On or about November 24, 2000, Defendant MAMSI forwarded a letter to Best indicating that "Juan Rosario is not eligible for coverage under (Best's] Group Life and Disability Policy." A copy of dlis letter is attached hereto as Exhibit "C". rl 13. The Group Risk Assessment referred to in the November 24, 20001etter does not indicate that fulfillment of the active work requirement was a condition of coverage. See Exhibit "C". 14. The Group Risk Assessment contains neither definitions nor any other binding terms pertaining to eligibility. 15. At no time did Defendant MAMSI contact Plaintiff Rosario regarding her entitlement to the proceeds of the policy. 16. On or about June 25, 2001, Plaintiff Rosario obtained a copy of the policy in effect for the Year 2000. See Exhibit "D", Cover Letter and Policy. 17. Contrary to the denial letter of November 24, 2000, the policy clearly and unequivocally provides that "An insured may remain in an eligible class for a limited time if active fill-time work ceases due to disability; leave of absence, layoff, or change to a part-time status." See Exhibit "D", Policy, p. 10 (emphasis in original). 18. On or about June 8, 2000, Mr. Rosario became totally disabled as a result of the cancer, which had progressed from his lung to his brain. 19. Mr. Rosario applied for and received Social Security benefits in the form of Supplemental Security Income. 20. Under the terms of the Group Life Insurance Policy, coverage would continue until "the end of the 12 policy month period that next follows the end of the policy month in which that person last worked as an active full-time employee. See Exhibit "D", Policy, p. 10 (emphasis in original). 21. Under the terms of the Group Life Insurance Policy, coverage should have continued until at least June 30, 2001. 22. Mr. Rosario died within three months of the date of the onset of total disability, well before the expiration of the 12 month coverage period mandated in cases of disability. 23. To date, benefits have not been tendered by Defendant MAMSI to Plaintiff Rosario. 24. The amount of the death benefit was $10,000.00. 25. On or about August 10, 2001, the undersigned attorney sent a letter to Defendant MAMSI requesting payment of benefits within ten (10) days of the date of the letter. A copy of the August 10, 2001 letter is attached as Exhibit "E". As of August 31, 2001, no response has been received. COUNT I -Breach of Contract Plaintiff Rosario v. Defendant MAMSI 26. Plaintiff incorporates paragraphs 1 through 25 as if fully set forth herein. 27. As the designated beneficiary, Ms. Rosario is entitled to the proceeds of the Group Life Insurance Policy. 28. The Group Life and Disability Policy requires "Interest will be paid on proceeds not paid with 30 days after the death of the Insured. The rate will be declared by [MAMSI] but will never be less than 4% per annum." See Exhibit "D", Policy, p. 5 (emphasis in original). ~; ~;~,:. 29. Plaintiff Rosario is entitled to interest on the proceeds in an amount not less than 4~o per annum from the date MAMSI was informed of Mr. Rosazio's death. 30. Defendant MAMSI's failure to pay the amounts due and owing to Plaintiff Rosazio as more fully set forth above constitutes a breach of the Group Life Insurance Policy. WHEREFORE, Plaintiff Rosario requests that this Honorable Court enter judgment in her favor and against Defendant MAMSI in the amount of $10,000.00 plus interest as required by the Policy, an amount not to exceed $25,000.00, requiring compulsory arbitration in the County of Cumberland. COUNT II -Bad Faith Plaintiff Rosario v. Defendant MAMSI 31. Plaintiff incorporates paragraphs 1 through 30 as if fully set forth herein. 32. The language of the policy is clear and unequivocal that in the case of total disability, coverage would continue for at least an additiona112 months after the date of onset of disability. 33. Defendant MAMSI's assertion that Juan Rosario is not eligible for coverage under the Group Life and Disability Policy due to him not fulfilling active work requirements is in direct contravention to the clear and unequivocal language of the Policy mandating coverage for at least 12 months after the onset of the date of disability. 34. Defendant MAMSI's voiding of Juan Rosario's life insurance coverage, demonstrates a reckless disre~~ard for the righPs of the insured. ;,,, L' 35. Defendant MAMSI's refusal to pay proceeds to Plaintiff Rosario on the basis stated in its November 24, 20001etter demonstrates a reckless disregard for the rights of the insured. 36. Defendant MAMSI's refusal to pay proceeds to Plaintiff Rosario is frivolous and unfounded. 37. Defendant MAMSI's refusal to provide benefits, as well as Defendant MAMSI's actions and omissions as more fully set forth above, constitutes bad faith under 42 C.S.A. § 8371. WHEREFORE, Plaintiff Rosario requests that this Honorable Court enter judgment in her favor and against Defendant MAMSI in the amount of $10,000.00 plus interest as required by the Policy, together with attorneys fees, court costs, interest and punitive damages to be calculated in accordance with 42 Pa.C.S.A. § 8371, an amount not to exceed $25,000.00, requiring compulsory arbitration in the County of Cumberland. Dated: U -~~ y' Respectfully Submitted, LATSHA DAVIS & YORE, P.C. By: ~ ~ Steven M. Montresor Attorney I.D. No. 74244 P.O. Box 825 Harrisburg, PA 17108 (717) 761-1880 Attorneys for Plaintiff, Frances M. Rosario .~~~ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA FRANCES M. ROSARIO, as named beneficiary under the Group Life Insurance Policy of her father, Juan Rosario, Plaintiff v. NO. MAMSI INSURANCE RESOURCES, LLC, t/d/b/a MAMSI LIFE AND HEALTH INSURANCE COMPANY, Defendant CIVIL ACTION -LAW VERIFICATION I, Frances M. Rosario, hereby state that I am the Plaintiff in the within action and further verify that the facts set forth in this Complaint are true and correct to the best of my knowledge, information and belief; and acknowledge that the statements in said Complaint are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. DATE: / Frances M. Rosario ,.~~ ,;.z CERTIFICATION OF COVERAGE Policyholder: Inturad Parson: Policy Number: Certificate Number: tificate Effective Date: Beneficiary: Death Benefit: Depen Suppl L Death Benefit: BEST PONTIAC-OLDS-CAD-OHC ROSARIO, JUAN 23338 582767267 O1 FEB 2000 FRANCES N ROSARIO $10,000.00 (reduces to 65~ at age 65, terminates at age 70,) $0.00 $0.00 - I ~-~.u,4., ~~...~ rest ant .~ i. , b x This is to certify [h.a[ the information here given is correa!y copied. trom an original certificate ak dea.th duly tiled with me as LE9ca1 Regisrrar. Thz original certificate will be forwarded to the State Vical Records OfFce for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 6669143 No. ~r.LCJ-'~G•qF~~ Local Registr r s~ az zaoo Dale COMMONWEALTH Of PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH iYf .IL:,WEEIi f%OECf Of Ni R•Y Uroa:.pl $Ea SCC,45ECVR~rY~NNBER O,IEOE CEniN:,grna OEa 1+N 1 Juan Rosario Sr. _ Malt =. 5$J. - 1b - 1dV7 Sepl~ b, tow AaYFWh VNCEP YExfl V1CE0.ipp 9YEGi 8bRN ' WRi1tICEx,. Y< pVCEK CEaNM1nR. m,Erry-.ER,TVOwaG~ ~• YvM. • O,.• ltvf •v Y i M 4 iYNVECa9'CW,e,I NO$hLt TNER' '/} 5 " V ~ f E Oct II !4 `~- , R ~~ p~ UM xo•,~.r C ERK}KUnN 1 j DOa G ~ o Rw6ti p~ S .M1pf DEFN CRV.NPo.IVMCE OE,iN FwCA1T'x, p m. Y.•uen,w XNS OECEOEMOG MSMNCORpp, MCf.,:n••C,n NJ•n. b•[a. wA••wc n~ ,I~ Iyy y 1 p ~ PA ,w^w.I~E,... b.gruwntYl6R u 6 lvNaRw.•rc. rr `~rj 6 Ea ~yl S. ~u~l iEh SI' Ran . 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'J k ~ CT G ~.~2E ~.adcmmp•,Mpr -ro e.YA,nc.•p..m TuE Of pENN ~ OaE VNpN NCEppEwpluonm, p,r. rt+•~ Vats CwSE REiERREOIOR:~ EFAUwE0.tpRONER' ,.. .`T _S !~' N. ro xs. n ~U O C, n. .NT ~: EnNm•wru,...•.ry.Niwcwv.cwm.-r.enuinaa lM a,un pu nn.n•.Ox •oe•dpe.q,:ucn,a<ua aesv„~erT N.,NiKKaa, ne,n uwn ,App,o.nn Mm.: al.•. •.q~I<,n mna:ma me eu.gro ~ lm pnhwN C,uf•on ••fnM ~MmNp,rva•n ! erow e.e e,.m dw <E C A V5E1i.:n ~ ` • ' n MRfl rca n,Jtpnm•WNMpuw q.•n A g y (-/ /~~ OVE iONR+S,EMSEPhr ......T.Y.p..e,en. 2 Lt~ vwp n•me6„• CUE SO RT,S, CONSEWFNCE C/1 ( En. VNOEh.nerG V ~Y Rr o rywr a : ~ e~ - I WE i01CR hs,Ca+SEWEKE OFl o~e«.nun I I ~ x.uroes• HERE .urops. nNEnNCS NNER O<a.Lx o,rE O•~wuR. enE Cf iNrvPV iNNRVa Wy1Kl CESCRiEE MpViNIVR. Q:CN,xEO muED, uetf h,KM ~O IYenm oq m,.. CCUVtETpn CE C,JSE s INI F ivY O No-..co- • J p j D . ~ ~~ bn~ Q pertq in +.q,ion i] t~ )M u ~• . _~ aLl s. IJ Ne ~ 5"<d •~ Enwve. au.rm.ny ^ ...e ~xmW en U~o, .uCE p. ~NJVp• + opc• soot tCCRKM Rem CqM-• )•e _ , V Mry , < ~SO<•.i ]0. . ip ~,... E,.,.~..~.. ,: ~~,~.~. rn ....,.,..~...-._..~,~.. ...,..n,-,,.T,~..... -. __ ,~~., ~~ _l %~ _r / ... .r. .'Cl x.'.-. s. CiCE r l ~ sE OG 4~'d % F ,uE +NO .copE s s o. =r p ;o., w ,o r, ~~ Vin... p~r.no- wn - : - I ~i „ . ~., _. . CS ~l ~ --,. ~. r.pA ~ ... .. ~.~ ,7~T V _, . . • ~._, ~ C?1'T1~111h1 (y1A1ylsj_ r11.I.lANI.I ~ IvLD.I[A ci-ioicr:,.. ..-.-.:.,-..,,,.. rru MAI Sl November 24, 2000 Best Pontiac-Olds-Cad-GMC Altn: Charles Beans, Controller 100 l;isenhower Drive PO Box 79 Hanover, PA 17331 RE: .Juan Rosario - MAMSI Life and Health Insurance Company (MLH) Member - M582767267*Oi Dear Mr. Beans: It has come to the attention of MAMSI Life and Health Insurance Company (MLI-I) thae Juan Rosario is not eligible for coverage under your Group Life and Disability Policy. Please refer to page 1, #I of your Group Risk Assessment, it states, "Pull-time is defined to be employees working a minimum of 35 hours per week on a regular year-round basis." Information provided by your company shows that Juan Rosario's last day of work was June 7, 2000. At this time MAMSI Life and Health Insurance Company (MLI1) is voiding Mr. Rosario's Life and Disability Coverage due to him not fulfilling the Active Work Requirements. [fyou have any questions please call me at (301) 360-8703. Sincerely, By; /Gary Therkildsen Director Special Investigations MAMSI Life and Health Insurance Company (MLI I) cc: `lark Biancucci, Croup Services Kathleen Graham, Customer Support Suzanne Mayhew, Life and Disability i ,, -OS' 00(ii~Dl 09:42'. MAMSI HARRISBURG, PA TE6:117-791-0925 P. 002 ~S ~ ~ ` T urance'Compsany ~s~t ln Llt H ~~J N~ , e a and ealth ~ Applitation is hereby made %r.grnap ioriaragarjnr:eliglble ehiployaos and the ~ tliglbls dependens band on the following in formation: ~ :'~ h,~ :. ~otnpany Names .Pj~/7'./i!r1G;.~;1..' ,1~=D~-:.~'%~~;'t~/~~. J.~FrST ~ ~ iddreu: /OP ~/SENNt~sr/;EiC: i~'~'+ ~•`F'r';GO.~~,09f" ..~s-:.: _ . , : '11X3s3 An10V6L2 ~ .Ty <~Siate i~ • ' ~'~Zf .'Gelfcl~_r..~".: ic ~ .. :(7/9~ b~=s`7-31?I/ l hone: . y: : 85~l:.~ ~: L, W(4~TZ . ~. 'Title: L~,1d Jompany Official: 2~• r , . GNAiQ~:~S''~~` 7.7F..J4'A/6 'Tltlel 'anon to Conta:c: 2 LtE' ^ Mature of Buainent At.lTOMc77y~ •' .l,~RL~c/QSf~//~ . -oul No. of £mployeeu SB .'FuUtlinet Psrt-dme:.,~.t." ' U ion: Nn -. ' ~_q `'` ' ;~ umber enrolled: ~ -oul number of eligible employcn;~ . .. ,. Full-time is defined to be ern~loyea~•wo~km~ a'miiilittum of-~ haurljau week . - n a rttgularycu•rounti basis. ~/ ~ ~ _. Avenge number of full=dme'cmployeer for thta-put nvo yerra:...L ' -.' ~. Are union employees covered by itriother plan? '~A' ' ~ NO ^ YFS C J +• Arc SO%, of more, of your employees family mturibersP '~ r ,~ ^ YES !'i ~ (~O 77hac is the ttvcrage age of the rnrolled employees? Sri Requcjted.effectivcdsce: ~~ O ~ ire all eligible employees sctively.atvvockt ~ ~ ~ ES ~] NO Jo you have any employees age 65 orovcr acdvbly'atworkj,;.,. [U'S'ES [] NO JOTS. Vcciflculoa a(smploytrta+daambao{ hqun la rpu ird (er^II ca,ploycetsas 65 or o.er.~. ~ COMPANY ~A17TNG P?RIvD: ~~_ (?hit 4 the +mount o(time m employrr mutt M t loygd before belna dlaiblti for bcarfio.l mployec premium contribution to: Employee wverage:~9L;~: Dependent wveng . _ ~ % `:OTYa U i, yrced rhet U the Hnpkr•* p•P thr t.dr• caro(tbt,, tar 100% o(tlie Jlalble emday.„ mpn M mtk• raontt,ly p+yraA dtduttlom for lh+-Mtploru cunmbatlont. ~( say, (ot~aath~awployea .nrolllna {a the rercd. TL• +mplorrr .true. ra n<(Is ptoq»m. ire there any eucrent or prior employees or dependent covered undai COBRA? []YES (B NO [E YES, how many? Ipb+w lndlua omempbrh •pplludonl Jo you Nava any cmployeee or any knowledge of eniployt:n' dependents who live cur of the uea and who squire hnlth eovera$cd ~ ~ ^ t~ YES O If YES, number of employees of dependence,and where they are located: (0-rtT4~lf ;kf#S~t~Ucccifrx,h.~~c:th c~~zt.agcInclfc Piit 2 yaara2 ~ ~ ' ( i~ S 1~ Iv0 , ~ ,rl ' qI , (~ M1,txgi , ~ • ~ r , . - ,r ~ .t -t,G\-T ri) / r{77YY t1M ~tt ~~' _. . ~~' t r Y~_ t __~ •r i.'.. L. 't.. 1. .i r~`. .)~ __ ~ ~r ~~. _ i.Jr ~ ~ - ~ r ~ ~.. ' ~ .. . . ~ r ~ ~ ,wc~ z s 200 I r OPTIMUM MAMSI ALLIANCE M.D.IPA CHOICE.: ~~.~~.•••~~.~ rro June 25, 2001 Steven M: Montresor, Esq. Latshs, Davis & Yohe, P.C. PG Box 825 Harrisburg, PA 17108-0325 RE:.Juan Rosario, Sr. b•1AMSI Member No.: M582767267x01 Yota• File No.: 3d4-O1 Dear iVlr. Mcntrescr: As requested in ycur letter o; June 20, 2001, please find enclosed the Group Lif and Disability policy for Bes, Pontiac-Glds-Cad-GNIC, Group #2;338. This policy was in effect for the calendar year ~ OOU. Should you have an} questions or need additional information, please contact rae at (301) 360-87G3. Sincerely, ~/^ - . ~~ ~- ~ : ` Gary Therkildsen Director, Special Ir.~•e::tigations MAMSI Life and He~lt:^. Insurance Company(MLH) v ,. ~ ~w, ~~_; Life and Health Insurance Company Group Life Insurance Policy This policy is anon-participating policy a~~1;~~a1~, Ntn Form 100 GL (PA) .• TABLE OF CONTENTS MAJOR SECTIONS DEFINITIONS ................................................ 1 GENERAL PROVISIONS .......................................... 3 DEATH BENEFIT .............................................. 5 PREMIUMS .................................................. 5 CONVERSION OPTION .......................................... 7 ELIGIBILITY AND EFFECTIVE DATE ............................... 9 ACCIDENTAL DEATH AND DISMF_MBERMENT BENEFITS ................. 12 SHORT TERM DISABILITY BENEFITS ............................... 14 ~` DEFINITIONS The following terms which appear in bold italics throughout the Policy have special meaning. Active, Full-time An active employee performs all of the duties of a job with the Employee employer covered under this Policy. This job may be at either the employer's normal place of employment or at another place to which the regular business operations of the employer required the employee to go. To be full-time, an employee must work for an employer covered under this Policy, at least 30 hours each week and on the regular payroll of the employer for that work. An active and futl-time employee, as defined above, may also include members of an association or employees of member firms of an association to which the Policy is issued. Insured means the person whose life is insured. Period Of Total This is the period of time that a person is totally disabled. New periods Disability due to the same or related causes must be separated by return to active work for 30 consecutive days or more. Periods due to different causes must be separated by a return to active work for at least one day. No new• waiting period will be applied if there are 30 or fewer days between periods of disability. Partial Disability means as results of the sickness or injury which caused total disability, the Insured is: `unable to perform one or more, but not all, of the material and substantial duties of any other occupation on a full time or pan time basis; Z able to perform all of the material and substantial duties of any occupation on a part time basis. Partially Disabled Policyholder Service Waiting Period see Partial Disability means the corporation, association, partnership or proprietorship that purchased this plan of group insurance. Thi. is the period of time, set forth in the application that the proposed insured is not eligible for coy-crage under this Police. r~,~~~~ iuuci.~t~:v Total Disability ~ means unable to perform the main duties of the Insured's occupation. After the ftrst continuous year, the Insured must be unable to perform the duties of any occupation for which the Insured is qualified by education, training or experience and is not engaged in gainful employment. Totally Disabled see Total Disability. Waiting Period The period of consecutive days of total disability for which no benefit is payable. The waiting period begins on the first day of total disability occurring after the effective date of coverage. We, US, Our refers to MAMSI Life and Health Insurance company. i:,~~;:~ nuu,i.~r~~ ' GENERA, PROVISIONS The Contract The Policy, the master application and the enrollment applications will constitute the entire contract. A copy of any application of the policyowner shad be attached to the policy when issued. Any statements made by the Policyholder or the Insured are considered representations and not warranties. Authority t0 No agent or other person has the authority to modify or change the Modify provisions of this Policy except by an agreement in writing signed by our president, our vice president or our secretary and the Policyholder. Certificates We will issue to the Policyholder for delivery to each Insured, an individual certificate. The Insured is the CertificatAholder unless otherwise specified. It will summarize the benefits of [he Policy, to whom the benefits are payable and the rights of the Certificateholder when the coverage ends. The Certificate is not a part of the Policy. It does not modify any of the conditions or provisions of [he Policy. Group Policy A copy of the Policy is at the office of the Policyholder. It is available Inspection for inspection by covered persons during regular business hours. Ownership Of The Policyholder is the owner of the Policy and may request changes or Policy an amendment to the Policy without the consent of the Insured, any assignee or beneficiaries. However, no change may affect the Insured's right to change the beneficiary or the right to exercise the conversion privilege, Essential Data The Policyholder will keep a record of the insured persons. This record will contain all of the data specified by us. Reports from this data will be furnished as needed for administering terms of the Policy and to determine premiums rates. Incontestability The Policy cannot be contested by us, after it has been in force during the lifetime of the lasured for two (2) years from the effecti~~e date. kept ii>r nonha}~ment of premiurs. No stxtcmcnt made by any hersnn :n,urcd unilcr the I'ulicy rola[ing to the in.curec!'.r in~urahilit~~ shall h~ Perm li)UGI,~PA) i ' used in contesting the validity of the insurance after such idsurance has been in force for two (Z} years during the Insured's lifetime unless such statement is contained in a written instrument signed by the Insured and a copy has been furnished to the Insured, his beneficiary or his personal representative. M1SStatemerit If the Insured's age, sex or any other essential data has been misstated, an equitable adjustment shall be made in the premiums or the amount of insurance. Any premium due will be based on the correct amount of insurance or rate. We will rely only on the data furnished by the Policyholder in making corrections. Beneficiary The Insured has the right to designate the beneficiary. This designation may be changed by the Insured any time unless it is a designation specifically stated to be inevocable.'Cltanging an irrevocable beneficiary will require the signature of the irrevocable beneficiary. The Policyholder may never be a designated beneficiary. The designation must be made in written form that is acceptable to us. The change will be effective on the date it is signed once it is recorded in the home office. Two or more named beneficiaries will share equally in the proceeds unless otherwise specified. If any beneficiary dies before the Insured, the rights and interest of such beneficiary will automatically terminate. Only those beneficiaries who survive the Insured are eligible to share in the proceeds. If no beneficiary survives the Insured, we will pay the proceeds to the Insured's estate. Assigriment The rights and proceeds may be assigned by the Insured. The assignment must be made in writing on a form acceptable to us. It must be an absolute assignment that transfers all rights of the Insured under the Policy, except those of an irrevocable beneficiary. The assignment may be made to one or more of the following relatives of the Insured: a spouse, children, parents or siblings. It may also be made to [he trustee of a trust for one or more of those relatives. IYe arc not responsible for the validity or results of die assignment. r<,~~~, uuu;i.ir,v ~ ' No benefit will be paid for any loss that results from or is caused Exclusions directly, indirectly, wholly or partly by: • intentional self-injury, suicide or attempted suicide, while sane; • a war or act of war; DEATH BENEFIT Payment of Upon receipt of proof of the death of the Insured, we will pay to the Proceeds designated beneficiary the amount of insurance shown in the Schedule of Benefits. Interest will be paid on proceeds not paid within 30 days after the death of the Insured. The rate will be declared by us, but will never be less than 4% per annum. If due proof of death is submitted to us more than 180 days following the date of death of the Insured, interest shall accumulate and be payable from the date the proof is submitted, to the date the policy proceeds are paid. Benefits will be paid in a single lump sum unless a settlement option is chosen during the life time of Insured.. Facility Of If there is no surviving named beneficiary, we may use our judgment Payment and pay up to $250.00 of the proceeds in total to a person(s) appearing to have incurred expenses in connection with a fatal illness or for the burial of the Insured. Any payment made in good faith, fully discharges us to the extent of the payment. Spendthrift Clause To the extent allowed by law, no benefit of the Policy is subject to the claim or legal process of a creditor of an Insured or a beneficiary. PREMIUMS When to Pay The first premium is due as of the effective date, and is payable in advance. Atl premiums after the first premium are payable on or before the date they are due and must be received by us in our home office. A receipt will be available upon request. Grace Period This Policy allows a grace period of 31 days for premium payments except the first. Premiums not paid on or before the due date, may be pail during thr it-da}' h~ri~u! inuncdiatcly follo~cing thr ~luc date. C~~~•rragc ~+~ill c~nnittuc ~lurinc ilic eri~~ pcri~,d. F„r: ~. I ~ ~nG l .i l':~ i ~ ~. t If the premium is not paid by the end of the grace period, all coverage will terminate. Continued Premiums due for an Insured who becomes totally disabled will be Coverage Without waived. Coverage will continue to be in force during the period of total Payment disability if: • the Insured ceases to be in an eligible class; • the disability starts while the person is insured under this policy and under age 60; • the disability has been continuous for at least nine (9) months; and • we approve the Insured as totally disabled. The amount of insurance is the amount that the Insured was eligible for at the start of the disability. The amount will reduce at the ages shown in the Application and terminate at retirement as if the person were not disabled. Proof of Disability Written notice and the first proof of total disability must be received by our Home Office within 12 months from the start of the period of total disability. Proof of continued total disability must be given as often as we deem necessary within 90 days of the date of request. After the first two years of total disability, proof will not be required more than once a year. We may require an examination at our expense made by a physician approved by us. Termination Of This Policy will terminate on the date of one of following events: The Policy • the date the grace period expires for nonpa}~ment of sufficient premium; or • the date the Policyholder requests termination of the policy. "termination of the Policy will not end coverage for an [nsurcd that is [otailt~ dLrabled. Coveraec will continue until [he earliest of • the ~_n~l ~,1~ ,i period of lofnl tllcttbl[itr. I~~a;n IOOGflP:U ~~ ~r Termination of Coverage • the date the Insured ceases to be totaf~y disabled • failure to provide written proof of continued total disability within the time required. The coverage on the Insured will terminate on the earliest of: • the date the Insured ceases to be a member of an eligible class; • the date the Insured's eligible class is eliminated; • the date the Policy is terminated; • the date premiums remain unpaid at the end of the grace period; • the date the Insured requests termination of coverage; • the date the Insured's employment or group membership terminates; • the date the Insured dies. CONVERSION OPTION Conversion Rights If the Insured's insurance coverage ends because of termination of group membership/employment or membership in the class or classes eligible for coverage under the policy, all or part of the amount of insurance that ceases may be converted to an individual policy of life insurance. If the policy terminates, or there is an amendment of the policy to terminate the Insured's eligible class, or an amendment to reduce the amount of insurance available in the Insured's eligible class, and the Insured has been covered under the Policy for at least five years, coverage may be converted for an amount not more than the smaller of: • $10,000.00; or • the amount oP the terminated insurance less the amount any life insurance for which the Insured becomes eligible under any other group policy within 3i dad's; provided that any amounts of insurance that shall have maun'ed ~a~i~~r u, tcrminati~ui are not includ«1 in the Form I~HKfI.~P:A. ~ amount of terminated insurance. Conversion Policy The conversion policy will be any type of individual life insurance policy, other than term life insurance, then being issued by us. The conversion policy will not include accidental death, disability or other supplementary benefits. It will be issued without evidence of insurability. The premiums for the conversion policy will be at our usual rate for its type and amount, the Insured's class of risk and the Insured age on the last birthday of its effective date. To exercise the conversion option, the Insured must submit a written application and the first premium payment within the conversion period. The conversion period is the 31 days immediately following termination - _ of all or part of coverage. The policy will take effect at the end of the conversion period. Death During the If the Insured dies during 'the conversion period, the amount of life Conversion Period insurance that would have been converted to an individual policy shall be payable under the group policy whether or not the application for the individual policy or payment of the first premium has been made. r,~~~~, iin~c;i.,r,~i s ELIGIBILITY AND EFFECTIVE DATE Eligibility Eligibility for coverage under this Policy will be effective from the first Requirements day that, as shown in the application, the proposed insured: • is affiliated with the Policyholder as an employee or group member; • is in an eligible classes; and • completes the service waiting period. No corporate officer or director will be eligible solely due to title. A partner or a sole proprietor will not be eligible solely due to position. If the proposed insured requests coverage above the maximum amount specified in the application, the Evidence of Insurability Requirement must be met. The proposed insured must be an active full-time employee to be eligible. There will be no multiple coverage for insured who are associated with more than one group covered under the same group policy. Eligibility of a member or employee of a covered group will be decided by the Policyholder. The total hours worked by an employee for all covered groups will be used in figuring full-time employee status. The service waiting period of a former employee whose employment was involuntarily terminated and who is rehired will be reduced if rehired within one year of termination or ceased work due to entry into the armed forces and returns to work in the time prescribed by law. In such a case, the employees period of service before leaving work will be credited toward the present service waiting period. Active Work An employee must be at active work for new coverage to take effect. Requirement Active work is work preformed an active, fieff-time employee. The employee will be considered at active work on a regularly scheduled non-working day if the employee is not then disabled and could have been engaged in active work had it been a work da_y and was engaged in acti~,~o work un the last prcccdin,~ re~~ular work day Pacn IUUGI_~I':1~ ,) r . If the employee is not at active work on the date that coverage. is to take effect, the effective date will be deferred until the first day that the employee is at active work and meets all other requirements need to affect the coverage. Evidence Of When evidence of insurability is a condition for coverage, it must be in Insurability a form set by us. All evidence required to evaluate the proposed Requirement insured as an acceptable risk must be given to us. The requirement will be met on the date we accept the evidence. Enrollment A proposed insured must enroll for coverage that is shown to be Requirement contributory in the application for it to become effective. Coverage is contributory when the Insured must pay all or part of its premium. Enrollment is tnaking written request for coverage on a form acceptable to us. The form may include a payroll deduction authorization that allows for the deduction of any required premium contributions from the employee's wages. The enrollment form must be completed and signed by the proposed insured. Effective Date Coverage will be effective on the first day of the policy month that coincides with or next follows the date the following requirements are met: • the Eligibility Requirement • the Active Work requirement • the Evidence of Insurability Requirement • the Enrollment Requirement. COritlnuatlOn .This provision applies to all coverage other than weekly income benefits During Non- that may be a part of the plan. An Insured may remain in the eligible Working Periods class for a limited time if active full-time work ceases due to disability; leave of absence, layoff, or change to a part-time status. I-Iowever, this continuance will be on the earliest of these times: • the date that the Inst<red's continuance in the eligible class is ended by the Policyholder. The date must be set in a way that aft employees ace treated the same; • for disability, the end of the 12 policy month period drat next lhllu~~~s the end of the policy month in which that person last w~n~krd as :ui ac•li~~e,(ull-(irate riuplo~'ce: Perm Iut1GL~P:A) • for leave of absence, layoff or change to part-time status, the end of the policy month period that next follows the end of the policy month in which the Insured last work as an active full-lime employee. However, this continuance will not apply to an Insured who is entering the armed forces of any country. While the Insured is being continued in an eligible class as stipulated above, insurance benefits will be based on the benefits of that Insured's eligible class on the last day of active, full-time work and are subject to the reductions in benefits of the Insured's eligible class. Form Ill(iG1.tP,Ai ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Benefit Payable If an Insured suffers a covered loss, other than loss of life, because of an injury caused by an accident, the loss must occur within 90 days after the date of the accident. Notice of the loss must be received by us within 30 days after the start of the covered loss. We will pay the benefit amount when we receive proof, satisfactory to us, of the covered loss, other than loss of life within 90 days of the date of the loss. A covered loss means: • loss of a hand by severance of four entire fingers; • loss of a foot by severance at or above the ankle; • total and permanent loss of sight. Benefit Amounts We will pay the full benefit amount as shown in the Schedule of Benefits for loss of: • fife; • sight in both eyes; • both hands; • both feet; or • any combination of foot, hand or sight of one eye. We will pay one half the benefit amount as shown in the Schedule of Benefits for loss of: • sight of one eye; • one hand; or • one foot. 1Ve will not pay more than full benefit amount shown in the Schedule of licnefits for all losses duc w the same accident. Payment O~ition5 Payment options may be elected for loss of life or dismemberment benefits in place of one sum payment. The options that are available are those offered by us at the time of election. Elections must be written in a form approved by us and received at our home office. Claims will be paid not more than 60 days after we received written proof of loss. The Insured may elect the payment option. That election may not be revoked after the Insured's death. If the Insured dies without choosing a payment option, the beneficiary may elect the payment option. The payee must be a natural person who takes the benefit in to his or her own right. Exclusions No benefit will be paid for any loss that results from or is caused directly, indirectly, wholly or partly by: • intentional self-injury, suicide or attempted suicide, while sane or insane; • bacterial infection, unless the infection results from an accidental bodily injury; • a physical or mental sickness or treatment of that sickness; • voluntary intake of poison except accidental food poisoning, drugs, gas or fumes except in the course of employment; • a war or act of war; • disease of any kind, and any treatment of such disease; • participation in a riot or other civil disorder • an attempt [o commit, or committing felony or an assault (except in self defense); • flight in an aircraft or spacecraft, or descent from such a craft while in flight, or subsequently drowning, if the insured is a pilot or officer or crew of the craft, is giving or receiving aviation training, has duties relating to the craft or is being flown for the purposes of descent froth the aircraft. • being legally intoxicated as defined by the law in the state in which the policy is delivered or under the influence of any drug unless it ~cas prescribed for the Insured by a doctor. Form IOOGL(PA> I ; t a SHORT TERM DISABILITY BENEFITS The benefits described in this section are optional. If elected, the Weekly Benefit, Maximum Number of Weeks Payable and Waiting Period referred to in this section are specified under Schedule of Benefits in the application. Short Term If the Insured becomes totally disabled while insured under this policy, Disability Benefit we will pay benefits during the period of total disability at the rate of the Weekly Benefit per week, not to exceed the Maximum Number of Weeks Payable, for any one period of total disability. The Insured must provide proof that the disability is due to anon-occupational sickness or injury and that the regular attendance of a physician is required. Proof must be sent within 30 days after the waiting period. Benefits will begin after the expiration of the waiting period, if any. _- __ Duration of Weekly benefits will be paid up to maximum benefit period. The benefits Benefits will end on the earliest of: • failure to submit required proof of continuing total disability; • the date total disability ends; or • the date the maximum benefit period ends. Successive periods of total disability separated by less than two weeks of active work, on a full time basis shalt be considered one period of total disability unless the subsequent period of total disability is due to injuries or sickness entirely unrelated to the causes of the previous disability and commences after return to active work on a full time basis. If coverage under this Policy ends while the Insured is totally disabled, payment under this benefit will continue as if coverage was still in force under the Policy, for that disability only. No benefit will be paid for a disability that results from or is caused Exclusions directly, indirectly, wholly or partly by: • a mental disorder, chronic alaiholism or drug dependency, except while con(incd as a hc~i patient in a medical care facility; Ian in li~n(~~.~. I':\i ~..~ f ¢ $ intentional 'self-injury, suicide or attempted suicide while sane or insane; • participation in a riot or other civil disorder • a war or act of war Benefit will not be paid for a disability when the Insured: • is not under the regular care of a physician; • performs any work for pay or profit; or • is receiving benefits under workers' compensation or similar law r~>n„ toocLrr:~1 ,~ w I~`r Sx~A DAMS & YoxE, P C. ATTORNEYS AT LAW - PLEASE REPLY TO: HarrlSblllg WRITER'S E-MAIL: SmOntreS@IdyIaW.COm August 10, 2001 Gary A. Therkildsen, Director Special Investigations MAMSI Life and Health Insurance Company P.O. Boz 935 Frederick, MD 21705 Kimber L La[sha Douglas C. Yohe•' Glenr, R. Davis Kevin M. McKenna"• Jonathan M. Crist Barbara G. Graybill Timothy W. Garvey' David C. Marshall Sceven'M. Montresor' Christine L. Sudlosv' Chadwick O. Bogar Duane P. Slone Also admi[[ed •NJ •'NC, MD rx~NJ~ DC RE: Juan Rosario, Sr. -- -- MAMSI Member No.: M582767267*Ol Our File No.: 656-00 Dear Mr. Therkildsen: We are in receipt of the Group Life Insurance Policy which you forwarded at our request on June 29, 2001. After reviewing the policy, we are in disagreement with your decision to void Mr. Rosario's coverage as stated in your letter to Charles Beans of November 24, 2000. Specifically, the policy states that "An insured may remain in an eligible class for a limited time if active full-time . work ceases due to disability; leave of absence, layoff, or change to a part-time status." See Policy, p. 10 (emphasis in original). Based on our investigation, it appears Mr. Rosario became totally disabled on June 8, 2000, and in fact applied for and was determined eligible for Social Security benefits. Under the terms of the policy, coverage would continue until "the end of the 12 policy month period that next follows the end of the policy month in which that person last worked as an active full-time employee." See Policy, p. 10. Accordingly, coverage should have continued until June 30, 2001. Mr. Rosario died on September 6, 2001, within three months of the date of the onset of total disability, well before the expiration of the twelve month coverage period mandated by the policy ict cases of disability. Based on the foregoing, we are requesting that you tender the policy proceeds to Ms. Rosario, the designated beneficiary, as soon as possible. If we do not receive a response within 10 days of the date of this letter, we will be forced to file the attached Complaint in order to protect our client's interest. If MAMSI does not agree to forward the proceeds of the life insurance policy to the designated beneficiary, we will have no choice but to construe MAMSI's actions as bad faith, due to the clear and unequivocal language of the policy. As you may be aware, Pennsylvania's ..... ...i. .e. .. `nc,. •.'I ', L:I. .... :.. r ':.: I:.. ,I ..v„ is\.~ Ir.ii1 .:0l.u,p~; .. i:l r, ~I.i~.41 ~~ Y ~ary~A. Therkildsen, Director August 10, 2001` Page 2 bad faith statute provides for interest, punitive damages, court costs, and attorneys' fees against the insurer at the discretion of the court if the court finds the insurer acted in bad faith. Thank you for your attention to this matter. Sincerely, ~~ Steven . Montresor R ~ ,. CERTIFICATE OF SERVICE I, Donald M. Lewis, III, Esquire, one of the attorneys for defendant MAMSI Insurance Resources, LLC, t/d/b/a MAMSI Life and Health Insurance Company, hereby certify that I have served the foregoing paper upon counsel of record this date by depositing a true and correct copy of the same in the United States mail, first-class postage prepaid, addressed as follows: Steven M. Montresor, Esquire Latsha Davis & Yohe, P.C. P.O. Box 825 Harrisburg, PA 17108-0825 KEEFER WOOD ALLEN & RAHAL, LLP ~~ ? Y - i'Donald Lewis III Dated: September ~, 2001 ,,, ti . . , . .. , CERTIFICATE OF SERVICE I, Donald M. Lewis, III, Esquire, one of the attorneys for defendant MAMSI Insurance Resources, LLC, t/d/b/a MAMSI Life and Health Insurance Company, hereby certify that I have served the foregoing paper upon counsel of record this date by depositing a true and correct copy of the same in the United States mail, first-class postage prepaid, addressed as follows: Steven M. Montresor, Esquire Latsha Davis & Yohe, P.C. P.O. Box 825 Harrisburg, PA 17108-0825 KEEFER WOOD ALLEN & RAHAL, LLP Donald M Lewis III Dated: September ~~, 2001 IAT SHA DAMS & YOHE, P.C. ATTORNEYS AT LAW PLI?ASE REPLY TO: HarrlSbUrg WRITER`S E-MAIL: smontres@Idylaw.com Kimber L Latsha Douglas C. Yohe'* Glenr. R. Davis Kevin M. McKenna"*" Jonathan M. Crist Barbara G. Graybill Timothy W Garvey'` David C. Marshall Steven M. Montresor* Christine L. Sudlo`v* Chadwick O. Bogar Duane P Seone August 10, 2001 Also admitted *NJ **NC, MD Gary A. Therkildsen, Director ***NJ, DC Special Investigations MAMSI Life and Health Insurance Company P.O. Box 935 Frederick, MD 21705 RE: Juan Rosario, Sr. MAMSI Member No.: M582767267*Ol Our File No.: 656-00 , Dear Mr. Therkildsen: VVe are in receipt of the Group Life Insurance Policy which you forwarded at our request on June 29, 2001. After reviewing the policy, we are in disagreement with your decision to void Mr. Rosario's coverage as stated in your letter to Charles Beans of November 24, 2000. Specifically, the policy states that "An insured may remain in an eligible class for a limited time if active full-time . work ceases due to disability; leave of absence, layoff, or change to a part-time status." See Policy, p. 10 (emphasis in original). Based on our investigation, it appears Ivlr. Rosario became totally disabled on June 8, 2000, and in fact applied for and was determined eligible for Social Security benefits. Under the terms of the policy, coverage would continue until "the end of the 12 policy month period that next follows the end of the policy month in which that person last worked as an active full-time employee." See Policy, p. 10. Accordingly, coverage should have continued until June 30, 2001. Mr. Rosario died on September 6, 2001, within three months of the date of the onset of total disability, well before the expiration of the twelve month coverage period mandated by the policy in cases of disability. Based on the foregoing, we are requesting that you tender the policy proceeds to Ms. Rosario, the designated beneficiary, as soon as possible. If we do not receive a response within 10 days of the date of this letter, we will be forced to file the attached Complaint in order to protect our client's interest. If MAMSI does not agree to forward the proceeds of the life insurance policy to the designated beneficiary, we will have no choice but to construe MAMSI's actions as bad faith, due to the clear and unequivocal language of the policy. As you may be aware, Pennsylvania's Post Office Box 825 • Harrisburg, PA 17108.0825 4720 Old Gettysburg Road, Suite ]O] • Mechanicsburg, PA 17055 • (717) 761-1380 • FAX (717) 761-2286 7 Great Valley Parkway, Suite 221 • Malvern, PA 14355 • (610) 251.6435 • FAX (610) 407.9265 3000 Atrium Way, Suite 251 • Mc Laurel, NJ 08054 • (856) 231-535I • FAX (856) 231-5341 Maryland Telephone: (410) 727-2810 68868