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IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK, a minor
No. 0.3 - "3 (. '1 :I
PETITION FOR LEAVE OF COURT
TO SETTLE AND COMPROMISE MINOR'S CLAIM
Pursuant to Pa. R.C.P. No. 2039(a), Petitioners, by and through their attorney,
Karl E. Rominger, Esquire, petitions this Honorable Court for leave to settle and
compromise the uninsured/underinsured personal injury claim of Matthew Brink, a
minor, and in support thereof avers as follows:
1. Petitioners are Tom and Lisa Brink, the natural parents of Matthew Brink, a
mmor.
2. Petitioners Tom and Lisa Brink and their son reside at 75 Newburg Road,
Newburg, Cumberland County, Pennsylvania.
3. The minor child, Matthew Brink, was born on December 31, 1991, and is 12
years of age.
4. On or about October 10,2000, the minor child, Matthew Brink, was struck by
a motor vehicle while riding his bicycle in Newburg, Cumberland County, Pennsylvania,
outside of his home.
5. Matthew suffered traumatic injuries, including closed head trauma, loss of use
ofan eye, and numerous other debilitating conditions which are more fully described in
the Life Care Plan attached as Exhibit" An.
6. As a result of the closed head trauma, Matthew has also suffered a loss of
faculties and mental capacity which is more fully described in Exhibit "B", Vocational
Assessment.
7. The child's parents have endured great financial expense, and the child's
mother missed at least one (1) year of work immediately after the accident.
8. Tom and Lisa Brink need the reliable transportation ofa handicapped
accessible minivan to make transporting Matthew to and from the family easier and more
comfortable.
9. There is and has been extensive work ongoing in regards to a third party
tortfeaser action against the driver of the vehicle and other responsible individuals. The
parents and counsel are actively pursuing over one (1) million dollars in other coverage.
10. Harleysville Insurance is a corporation located at P.O. Box 1016
Moorestown, New Jersey 08057-0916 and by and through its' representative, Ann Pilla
has offered to tender a settlement at the Policy Number: P AA356429 which belongs to
the guardians of said minor and covers under its' uninsured/underinsured portions said
mmor.
11. However, at this juncture, Harleysville Insurance which is the first party
carrier for Tom and Lisa Brink, have agreed to settle for their policy limit and have
waived their subrogation rights (See Exhibits "e" and "D").
12. Originally, Harleysville Insurance took the position that the policy limit was
$15,000.00, but undersigned counsel was able to show, after careful examination of the
relevant records, that the stacking options of the policy was not properly waived and that
the applicable limit was thus $60,000.00 given the four (4) vehicles owned by the Brinks.
Exhibit "E."
13. It is proposed that the $60,000.00 once received be distributed as follows:
(a) Twenty-seven (27%) percent as a fee pursuant to a fee agreement
signed with Rominger & Bayley to the Law Firm of Rominger & Bayley;
(b) Fifteen Thousand ($15,000.00) Dollars paid directly to the parents for
the care and upkeep of the minor child, including the purchase of a used
minivan which would have better handicapped access than the current
automobile owned by the parents;
(c) Ten Thousand ($10,000.00) Dollars to be used by the attorneys for the
guardian of the child for expert expenses past and present, including any
and all litigation expenses which may have accrued or accrue in the
furtherance of the litigation against the third party tort feaser; and
(d) The remaining balance of the Sixty Thousand ($60,000.00) Dollars to
be placed in an account which is federally insured and interest bearing and
to be held until Order of Court and otherwise managed in accordance with
the Rules of Civil Procedure.
14. Petitioners believe and therefore aver that a settlement and distribution of
funds for the minor is fair and just and should be approved by the Honorable Court and
have executed an Affidavit of Consent which is attached hereto and made part hereof and
identified as Exhibit "F."
15. This Petition for Leave of Court to settle and compromise a minor's claim is
based only upon the uninsured/underinsured portion of the first party benefits available
and is no way intended by the parties to set a value for any underlying action, nor to limit
in any way any underling action against any third parties and is solely a compromise and
settlement between the first party benefit provider and the minor, Matthew Brink and his
parents.
WHEREFORE, Petitioner prays that this Court approve the above-described settlement
proposed on behalf of the minor child.
Respectfully submitted,
Date: J; ~ ~ ~ L (jo3
:2 '
.
~ ---
1 E. Rominger, Esquire
155 South Hanover Street
Carlisle, PA 17013
(717) 241-6070
Supreme Court ID # 81924
Attorney for Petitioner
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK, a minor
No.
CERTIFICATE OF SERVICE
I, Karl E. Rominger, Esquire, attorney for Tom and Lisa Brink, do hereby certifY that I
this day served a copy of the Petition/or Leave o/Court to Settle and Compromise Minor's
Gaim upon the following by depositing same in the United States mail, postage prepaid, at
Carlisle, Pennsylvania, addressed as follows:
Harleysville Insurance
Ann Pilla, Claims Representative
P.O. Box 1016
Moorestown, New Jersey 08057-0916
Dated: )' u 17 27 2 if} '5
7~
Karl E. Rominger, Esquire
Attorney for Petitioner
.' I
. Susquehanna ~ehabilitation Services
~.~.oc.oo.~.~.m.~.m
www.srsrehab.com
Attention:
SRS Number:
Date of Referral:
Rominger and Bayley
Law Offices
155 South Hanover Street
Carlisle PA 17013
Karl Rominger
2002-111
9/11/02
To Account:
Date:
Client:
D.O.!.:
D.O.B.:
Disability:
November 17, 2002
Matthew Brink
10/14/00
12/31/91
Severe Traumatic Brain Injury
Right Hemiparesis
Multiple Orthopedic Trauma
Life Care Plan
Introduction:
Matthew Brink is a 10 year old male referred by you for the purpose of developing a Life Care
Plan to address the medical and non-medical disability lifetime needs and costs associated with
his disabling conditions secondary to a motor vehicle accident on 10/14/00.
A Life Care Plan is a comprehensive report which addresses the medical and non-medical
needs as a consequence of a catastrophic injury which projects the costs of needed items and
services over the person's anticipated life. This Life Care Plan is specific to the individual and
is not generalized to a particular disability.
Matthew Brink sustained multiple injuries including a severe closed head injury, hypoxic
ischemic encephalopathy, right adrenal hemorrhage, aspiration pneumonitis, .Iiver laceration,
right orbital fracture, and right temporal bone fractures of the face, a right brachial plexus
injury, a right olecranon fracture, left tibial fracture, and injury to the left lower ankle including
avulsed skin flap and tendon injury. He has right sided hemiparesis as well as visual
impairments on the right side due to optic nerve injury.
This Life Care Plan was prepared by a review of the medical records provided, a nursing
assessment visit to Matthew Brink on 9/26/02 at his home, and consultation with local
provider's offices and resources.
Records Reviewed:
1. Reports of Dr. Jeanette Ramer, Developmental Pediatrician, Hershey Medical Center.
2. Report of Pediatric Orthopedic Clinic, Hershey Medical Center.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450 / Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
E)(hibi-L ,IA t.
'Slisq~eh~nna ~ehabilitation Services
AA.~.OC.oo.~.~.m.~.m
www.srsrehab.com
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 2
3. Reports of Hershey Medical Center, inpatient and outpatient records,
4. Accident Report, 10/14/00.
5, Newburg Ambulance Records.
6. Records of Dr. Stephen Becker, Primary Care.
7. Report of Dr. BonsaIl, Ophthalmology.
8, Records of Shipp ens burg Area School District,
9, Records of Chambers burg Hospital.
Medical Summary:
The information contained within this medical history was taken directly from a review of the
available medical records.
10/14/00-11/6/00 Admission Hershey Medical Center
Diagnoses: Closed head injury, Hypoxic ischemic encephalopathy, Liver laceration, Right
adrenal hemorrhage, Aspiration pneumonitis. Open left ankle fract\lre, Left femur fracture. Left
tibia- fibull\ fracture.
Operations/Procedures: Placement of subarachnoid intracranial pressure monitoring bolt.
External fixation of the left tibia- fibula fracture, Incision and drainage of the left ankle.
Mechanical ventilation.
Hospital course: Matthew is an 8 year old boy who was struck by a motor vehicle while riding
his bike on the day of admission. There was positive loss of consciousness and he was down for
25 minutes, Upon arrival of EMS he was reported to have agonal respirations, He was
pharmacologically paralyzed but repeated intubation attempts failed, Upon arrival to the
Trauma Bay, the patient was noted to be unresponsive with a Glasgow Coma Scale of 3 with
hemodynamic instability. Trauma resuscitation protocols were followed and multiple blood
products including red blood cells and fresh frozen plasma were infused. The patients'
orthopedic injuries to his left lower extremity were addressed on Day # 1 and the placement of
an ICP bolt was also performed. Cervical spine precautions were foIlowed and his
hemodynamics were monitored, A Dopamine drip was started to maintain kidney perfusion on
Day #1. The patient's neurological status remained unchanged, There was no incidence of
intra-abdominal bleeding from the patient's documented liver laceration. IV steroids were
started for optic nerve injury. On hospital day #6 he was started on parenteral nutrition, Enteral
nutrition was then begun as tolerated, The patient's respiratory status was monitored for
aspiration pneumonitis and antibiotics were instituted, The patient was extubated five days
prior to transfer to rehab. He remained unresponsive with no vocalization, He remained on
antibiotics for positive tracheal aspirate cultures and positive blood cultures for staph infection.
He was discharged to rehab on IV antibiotics,
Sensitive To Your Rehabilitation Needs
Home Office: P.O, Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450 / Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. Sus~ueh~nna ~ehabilitation Services
~.~.oc.oo.~.~.m.~.m
www.srsrehab.com
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 3
11/6/00-12/21/00 Admission Hershey Medical Center Rehabilitation Unit
Final diagnosis: Severe closed head injury. Right hemiparesis.
History of present iUness: He was riding a bike and was hit by a car. There was a 25 minute
gap without care. When the emergency crew arrived he had agonal respirations. There was a
failed intubation at the time. His Glasgow Coma Score was 3 upon arrival to the ER. He had
decreased blood pressure requiring fluid resuscitation. Injuries included a severe closed head
injury. CT scan showed a small right occipital intraventricular hemorrhage, a right orbital
fracture, and right temporal bone fracture with pneumocephalus. He also had a left open
tibiofibular fracture, a right supracondylar fracture, and a right shoulder injury.
Complications in the acute setting included difficulty with ventilation, pneumonia, and
pulmonary edema. He failed extubation on the first try due to these problems. He was
successfully extubated on 10/31, but required oxygen until he was discharged to rehabilitation.
At the time of transfer he had become more reactive with spontaneous movements, the left
more than the right. He opened his eyes spontaneously, grimaced to discomfort, and had
semipurpo.seful movements of his left arm. There were no vocalizations.
Past medical history: Mild asthma. No other medical problems. He was described as a
hyperactive risk taking child. He attended third grade in the learning support placement.
Hospital course: Feedings were advanced to oral feedings. He had persistent right hemiparesis
with arm affected more than his leg. He also had facial weakness on the right side. He had
emergence of language 10 days prior to discharge. He began to use short phases and his
answers were accurate and clear. He had difficulty with word retrieval. He has significantly
impaired vision on the right. His functional motor skills improved and he was able to roll in
bed, get from sidelying to sitting with contact guard, sit in his wheelchair without assistance
and transition to standing. He could stand with one hand held for ten minutes. He had re-
emergence of allergies and was placed on Claritin.
Condition on discharge: Return to brain injury clinic. Therapies in the community 2-3 times
per week. He will be receiving homebound services from school.
1/4/01 Dr. Segal- Pediatric Orthopedics
Over the course of his "rehabilitation stay, a brachial plexus palsy on the right side was
determined. He has also developed bilateral equinus contractures. He is using his hand more on
the right side. A short leg cast was removed today from his tibia. X-rays reveal t he fracture of
the left tibia is healed, but in 10 degrees of varus. He has bilateral equinus contractures of 10-
15 degrees. Radiographs of the right elbow reveal the olecranon fracture to be healed and the
radial neck fracture to be healed. The small decubitus under his left heel has completely
resolved. He will be seen for removal of right elbow hardware and to address his equinus
contracture with heel cord lengthening. He is to have BoTox injections in the interim.
Sensitive To Your Rehabilitation Needs
Horne Office: P.O. Box 335/ Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. Sl1squeh~nna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE · NJ . NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 4
1/23/01 Dr Ramer- Developmental Pediatrician
He has had some progress in skills. Motor skills have shown improvement. Language is
improving more slowly. He was assessed by the therapy team today. Current areas of concern
include attention focus which is only 3-5 minutes for homebound instruction. He is incontinent
of urine, but not of stool. He has a recent sinus infection which was treated with Augmentin. He
had some wheezing this weekend and used an old inhaler with good results. He is tolerating
therapies and is ready to give up the wheelchair. He can walk with assistance at this point. He
still uses short phrases and has difficulty with word retrieval. Right hemiparesis remains
evident. He has a resolving hematoma on the occipital portion of his head. He also has an area
of imbedded glass in the abdomen which should work its way out. He will be entering the
Franklin Learning Center for school based therapies and learning support. He is to wean off
Zoloft.
2/1101 Dr. Segal- Pediatric Orthopedics
He sustained multiple injuries including a severe closed head injury, a right brachial plexus
injury, a right olecranon fracture, left tibiiil fracture, and injury to the left lower ankle including
avulsed skjn flap and tendon injury. Underwent placement of an external fixator of his left
tibia. Underwent open reduction internal fixation with tension band wiring of his right
olecranon fracture as well as a non displaced right radial neck fracture. He has also developed
bilateral equinus contractures. The tibial fracture was healing well clinically, however it has
healed with 10 degrees of varus deformity. He was also noted to have bilateral equinus
contractures 10-15 degrees. He is to continue with physical therapy, progressive weightbearing,
and consider BoTox injections in his triceps to see if one could avoid heel cord lengthening. He
has been using a walker for one month.
Radiographs: Stress radiographs with varus and valgus stress of the tibia, which showed some
motion at this site.
We have tentatively scheduled the patient for future procedures, including removal of hardware
from his right elbow and addressing his equinus contractures.
Recommendations: Under one anesthetic, we can consider bilateral heel cord lengthenings,
removal of the hardware from his right elbow, and addressing his nonunion varus deformity
with open reduction and internal fixation with iliac crest bone grafting. He has been placed in a
short leg cast for stability and will continue PT.
3/8/01 Pediatric Orthopedics
Impression: He is scheduled to have hardware removal of his right olecranon fracture, bilateral
heel cord lengthenings for equinus contractures, and correction of the left tibial nonunion with
iliac crest bone grafting. He has been tolerating his short leg cast.
Plan: Obtain x-rays of his right shoulder and x-ray of the tibia out of the cast.
Sensitive To Your Rehabilitation Needs
Horne Office: P.O. Box 335/ Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
'Susquehanna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA . wv · DE · NJ . NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 5
3/27/01 Dr. Ramer- Developmental Pediatrician
He is on Bonine for nausea. He is taking Sudafed and Flonase for congestion. His biggest
problem is recurrent sinusitis. He is receiving PT, OT and speech at the Franklin Learning
Center. Speech clarity remains poor. He become frustrated and angry. He will calm down if
sent to his room. He has shaking of his left ann and this makes it difficult to self feed and his
parents have to intervene. This makes him angry. He also has tremor with writing. He has
balance issues but is walking well.
Impression: Ongoing issues are recurring sinusitis, non union of the left tibia, and continued
deficits in learning. He is to have an ENT referral. This could be related to his facial fractures.
5/9/01-5/11/01 Admission Hershey Medical Center
Admission diagnoses: Left tibial non-union. Right olecranon hardware.
Procedures: Open reduction and internal fixation of left tibial non-union. Hardware removal of
right olecranon.
Hospital course: He underwent the above procedures without complications. He progressed to
physical therapy.
Discharge. instructions: He will continue routine cast care and remain non weight bearing left
side. To use crutches or walker for ambulation. He will continue elbow range of motion
exercises at home.
5/24/01 Pediatric Orthopedics
Now returns two weeks post removal of hardware from right olecranon and left tibial
osteotomy for varus deformity. He has been tolerating his long leg cast. Sutures were removed.
X-rays show interval healing of the tibial osteotomy site. The tibia is healed in slight valgus. He
will have his cast shortened.
6/21/01 Pediatric Orthopedics
He underwent left tibial osteotomy for non-union. He is wearing his long leg cast. He is using
his right upper extremity more. X-rays reveal interval healing. There is a gap noted at the
osteotomy site which is in 7 degrees of valgus.
Plan: Continue PT. Long leg cast changed to short leg cast.
6/26/01 Dr. Ramer- Developmental Pediatrician
He is receiving PT, OT, and speech at school. He is having difficulties with concentration and
attention. The tremor in his left ann is less visible. He is able to feed himself unless he is eating
soup. He can drink from a soda bottle without too much spillage. His right ann is still weak. He
has a cast on his left leg due to non-union left leg. He has poor judgment and memory issues.
He has a scanning quality to his speech and interrupts. His answers are not well organized.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. Susqueh~nna ~ehabilitation Services
~.~.oc.oo.~.~.m.~.m
www.srsrehab.com
Rominger and Bayley Law Offices
Re: Matthew Brink
~ovember17,2002
Page 6
Impression: Significant motor and cognitive impairments. He is receiving appropriate school
and therapy services. Additional PT may be needed.
7/23/01 Pediatric Orthopedics
He is 2 Y, months post left tibia osteotomy. He underwent compression plate fixation of the left
tibia osteotomy as well as removal of the hardware from his right elbow. He is still not moving
his right shoulder. He has been compliant with non weight bearing left leg. X-rays of the tibia
reveal a gap at the osteotomy site with no distinct evidence of healing.
Plan: Repeat x-rays. Discontinue cast and give Carn Walker. EMG for right brachial plexus.
PT for non weight bearing at school.
9/6/01 Pediatric Orthopedics
He is four months post left midtibial osteotomy. He is using a Carn walker. He is still having
weakness in his right shoulder. Radiographs reveal continued delayed non-union at the
osteotomy site.
Recommendations: Observe for two months- may need surgery. Continue PT for right
shoulder a~d do EMG for brachial plexus.
11/1/01 Pediatric Orthopedics
He needs an EMG for his right brachial plexus injury. He is receiving physical therapy for his
right shoulder. He is in a Carn Walker with limited weightbearing left leg. X-rays suggest
interval healing. He is to continue PT and Cam Walker.
12114/01 Dr. Ramer- Developmental Pediatrician
He is attending a school program which is a combination of regular classroom and learning
support. He receives PT, OT, and Speech once per week and has an academic aide with him.
He gets frustrated easily and has a problem with memory, especially short term memory. He is
able to dress and bathe himself He can only walk short distances due to persistent non-union of
his left tibia. He is using a Cam walker. He continues to gain weight. He is complaining oflow
back pain when he sits. He has significant pelvic tilt. He is in appropriate placement at school
and therapy. He has difficulty initiating voiding and requires an effort to void. He has problems
dribbling and soiling himself with urine after voiding. A urology evaluation with Dr. Dector is
appropriate. His weight is a concern and will impact negatively on his mobility and pulmonary
function.
12/27/01 Pediatric Orthopedics
He went on to develop left tibial malunion post tibial osteotomy, despite compression plating.
Repeat x-rays revealed further evidence of widening at the osteotomy site with apparent
hypertrophic nonunion. He has been walking in a limited fashion with the carn walker. He has
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 170508
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
Susquehanna ~ehabilitation Services
AA.~.OC.oo.~.~.m.~.m
www.srsrehab.com
Rominger and Bayley Law Offices
Re: Matthew Brink
- November 17, 2002
Page 7
surgery set for 3/26/02. He is to have his EMG for brachial plexus on 1/10/02. We have
tentatively recommended Iliazarov external fixation with compression mode of his
hypertrophic nonunion and fibular osteotomies with plate removal. May want to consider take
down of the pseudoarthrosis and bone grafting at the time of the Iliazarov application which
will allow the patient to weight bear.
1/10/02 Report ofEMG
Interpretation: Abnormal study. The electrodiagnostic findings show chronic partial
denervation and re-innervation which is present in C5 innervated muscles and to a lesser degree
C6-7 innervated muscles. There is no evidence of active/ongoing denervation. This is
consistent with residual right brachial plexopathy affecting his upper trunk, which is now
relatively mild. There is nearly complete re-innervation of the muscles supplied by the middle
trunk.
2/25/02 Pediatric Orthopedics
He is being followed for a delayed union/non-union of the left tibia post tibial osteotomy, still
wearing hJs Cam walker. There is less than a 1 cm gap at the non-union site. He is to have
capacitance coupling and electrical stimulation to attempt healing without operative
intervention.
Plan: Return with x-rays in 10 weeks. He had an EMG for his right brachial plexus palsy
which showed further regeneration. He will continue OT for his right upper extremity.
2/28/02 Dr. Bonsall- Ophthalmology
He has a history of traumatic optic neuropathy and now has no light perception in his right eye.
He also has exotropia. The parents are not interested in eye muscle surgery at this time due to
upcoming leg surgery. He has a history of asthma and combative behavior.
Impression: Developmental delay secondary to brain injury_ Exoptropia which is sensory.
Traumatic optic neuropathy. To be seen yearly.
5/9/02 Pediatric Orthopedics
He has been receiving electri~al stimulation capacitance coupling for a delayed union of his left
tibia. Radiographs reveal interval healing. The osteotomy line is clearly less distinct. He has
had the stimulator on 24/7 for 13 weeks. He has been bearing some weight on his left lower
extremity. EMG showed residual right brachial plexopathy but there is near complete re-
innervation of the middle trunk noted.
Recommendations: Continue with electrical stimulation for one month. Continue with Carn
Walker. May increase and progress to full weight bearing.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450 / Fax: 717-795-6204 / E-Mail: srs@srsrehab.com
. Susqueh~nna ~ehabilitation Se~vices
M.~.OC.oo.~.~.m.~.m
www.srsrehab.com
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 8
5/10/02 Initial PT Evaluation- Hershey Medical Center
Matthew underwent orthopedic surgery on 5/9/01 at which time he had right heel cord
lengthening as well as realignment of the le1!..tibia. He currently has a Cam walker on his left
lower extremity. He only uses his wheelchair at school but is walking independently at home.
Recommendations: He should continue PT at school to continue focusing on strength,
coordination, and dynamic standing balance. He would benefit from increased physical therapy
in the summer. He may need an alignment assessment due to leg length discrepancies. He does
not need the wheelchair in school but should be supervised at all times when ambulating.
9/13/02 Dr. Ramer- Developmental Pediatrician
Follow up of severe brain injury. He continues to make slow improvement in walking. Sinemet
was not of benefit for his tremor and was stopped. He has continued to receive PT and OT with
slow improvement. The occupational therapist feels he has plateaued in arm use skills. Tremor
remains an issue. It is most evident when he is fatigued and tries to feed himself It also
interferes with handwriting to a lesser degree. He continues to have excessive appetite and
weight gain. He is getting exercise by walking more. His learning skills are progressing slowly
and by the. end of school were thought to be plateauing. He can take care of most of his daily
care needs that are within his physical capability, but his learning of academics has been slow.
He is in learning support placement full time.
On examination his speech was slow and it was difficult to find words. His answers were
accurate, but superficial and brief His right shoulder has markedly reduced strength. He had to
brace his elbow to use his right hand. Tremor is present on the left and related to weakness. His
gait and balance have improved. There were problems with foot position on the right and a
MAFO brace is pending.
Impression: Tremor related to weakness. To try a weighted arm bracelet to help with tremor.
This will also help strengthen the arm. He was given a prescription for PT and OR outside of
school. He will try Aricept initially at 2.5 mg per day and increase over one month to 5 mg/day.
This medication may help improve memory and reasoning skills.
Current Medical Status:
Matthew is followed at Hershey Medical Center by Dr. Ramer, developmental pediatrician and
physical medicine and rehabilitation specialist, Dr. Segal, orthopedic specialist, and
Dr. Bonsall, ophthalmology. A urology consultation has been recommended for continued
urinary hesitancy and incontinence. Matthew has had an increase in sinus infections which
Dr. Ramer relates to narrowed passages secondary to the facial trauma he sustained and is
followed by his primary care physician for this condition and for coordination of referrals.
Matthew receives outpatient physical and occupational therapy in addition to mandated
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335/ Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
'Susq~eh~nna ~ehabilitation Se~vices
m.~.oc.~.~.~.m.~.m
www.srsrehab.com
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 9
services through the school. Matthew's left tibial fracture, despite osteotomy surgery and bone
stimulation, has healed with some degree of displacement and when he is at full bone growth,
will require repair with an external fixation device. He may also need bilateral heel cord
lengthening procedures in the future. Matthew has exotropia from the accident and may also
require eye muscle corrective surgery in the future for his right eye. Dr. Ramer has projected
that he may need tendon transfer surgery for his right brachial plexopathy. Matthew has visual
impairments and cognitive impairments and is a candidate for assistive technology such as low
vision aids and computer technology to increase his educational and vocational potential.
Matthew is currently on Aricept, a medication which is used to improve cognitive skills and
attention. He was on Sinemet for tremors but this was discontinued. He is on antibiotics at least
yearly for sinus infection. Matthew has a history of asthma and continues on inhaler
medication.
Chief Reuorted Problems Includinl!: Limitations and Cauabilities:
MatthewJlas severe impairments as a result of his disabling conditions. He has visual
impairments on the right side. He has cognitive impairments including attention and
concentration problems, difficulty with short term memory, impulsivity, and emotional
outbursts. He has weakness on the right side as well as gait dysfunction requiring bracing for
both legs. He continues with little movement of his right shoulder and he must use his elbow to
brace himself so he can use his right hand. Matthew needs constant verbal cueing and
prompting to complete his morning tasks as motivation is difficult for him. He has difficulty
with lower extremity dressing and tying his shoes. Matthew has low back pain due to leg length
discrepancies which has resulted in a pelvic tilt. He has gained significant weight which puts
further stress on his musculoskeletal system. Due to excess weight, he often has fungal
infections in the folds of his skin. The tremor in his left arm has led to difficulty with self
feeding and in bums due to spilling hot water.
Records and consultation with Dr. Ramer, developmental pediatrician, indicate that Matthew
will likely not be able to live independently due to injuries sustained from this accident. This is
due his cognitive difficulties and high need at present for learning support. Dr. Ramer has
indicated that it is not likely that he will be competitively employed but may be able to work at
a sheltered workshop level of employment.
-
Environmental/Social:
Matthew is the youngest of several siblings and is the only child still living at home with his
parents. His father is permanently disabled from a stroke he sustained in 1995 and he is also
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450 / Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. Susq~eh~nna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE . NJ · NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 10
legally blind. He had worked as an electrician and minister prior to his illness. Matthew's
mother works two jobs as a newspaper reporter and as records clerk for the Newville Police.
The family lives in a ranch home with a basement.
Educational:
Matthew is in full time learning support for academic subjects and is mainstreamed with the
regular classroom for specials such as art and music. Dr. Ramer has projected that he will need
special education throughout his school career. He will need assistive technology support for
computer use due to his visual and cognitive impainnents which may include voice technology
and special software options.
Summarv:
Matthew Brink is a 10 year old boy who has sustained multiple injuries which include a severe
closed head injury, hypoxic ischemic encephalopathy, right adrenal hemorrhage, aspiration
pneumonitis, liver laceration, right orbital fracture, and right temporal bone fractures of the
face, a right brachial plexus injury, a right olecranon fracture, left tibial fracture, and injury to
the left lower ankle including avulsed skin flap and tendon injury. He has right sided
hemiparesis as well as visual impainnents on the right side due to optic nerve injury. He has
deficits in motor, sensory, cognitive, physical, and socialization skills. Matthew will require
various medical treatments throughout his life as a result of these conditions. Matthew will
most likely require repair of the defonnity of his left tibia as his bone reaches growth maturity
in the teen years. He may also require heel cord lengthening procedures, BoTox injections,
tendon transfer surgery for his right upper extremity, and eye muscle surgery in the future,
though the likelihood of these procedures is less certain. Matthew will continue to require
treatment for frequent sinus infections related to his facial injuries.
Dr. Ramer has projected that it is unlikely that Matthew will live independently and that this is
due to the severe traumatic brain injury that he sustained as a result of his 10/14/00 accident. It
is also unlikely that he will be competitively employed but he may be able to work at a
sheltered workshop level. He will require 24 hour care and supervision. Future care alternatives
in this Life Care Plan consist of care at home and assisted living as an alternative. The Brink
family would benefit at this time from respite care due to time consuming and exhausting
nature of Matthew's care needs. When Matthew is an adult, he would benefit from facilitator
services to ensure safety and compliance with his rehabilitation plan. As an alternative he can
live in an assisted living facility which would include opportunities for socialization and
vocational training. It is likely that Matthew will live at home as a younger adult, but may
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. Susqueh~nna Rehabilitation 'Se~vices
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE . NJ . NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 11
require an assisted living facility as his parents age and are no longer able to care for him.
There are also extremely limited sheltered workshop opportunities close to the client's home.
Dr. Ramer has recommended continued outpatient physical and occupational therapy as an
adjunct to mandated services. These will need to be increased in the summer. His weight gain is
a concern and access to a YMCA type facility for swim and gym opportunities would provide
maintenance level exercise opportunities. Neuropsychological evaluations are recommended
for an assessment of Matthew's cognitive status both now and through the school years. I
recommend availability of psychological counseling and/or cognitive therapy at each stage of
developmental crisis to assist adaptation to disability and patient/family coping strategies.
According to the National Center for Vital Statistic Life Table for White Males, 1999, Matthew
has 65 (65.3) years remaining. This Life Care Plan and associated costs have been based upon a
normal life expectancy.
The Appendices that follow outline the anticipated lifetime care and costs for Matthew Brink.
Througho\lt his life there will undoubtedly be some alterations to these projected costs. Please
note all costs reflect current market prices and do not include sales tax, shipping, or handling.
All growth trends need to be determined by an economist. All opinions have been stated with a
reasonable degree of professional certainty. I request the opportunity to amend my report if
new information should become available.
Prepared and submitted by,
Va.leri.e- V. PCU"LW
Valerie V. Parisi, R.N., CRRN, CCM, CLCP
Certified Life Care Planner
Ivvp
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450 / Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
Home Care Option
ITEM ANNUAL COST YEARS ONEl1MElLIFEl1ME COSTS
Physical Therapy Evaluations $121.00 65 $7,865.00
Occupational Therapy Evaluations $121.00 65 $7,865.00
Neuropsychological Evaluations $4,200.00
Physical Therapy $7,744.00 11 $85,184.00
Occupational Therapy $7,744.00 11 $85,184.00
Case Management $180.00 65 $11,700.00
Behavioral Counseling $3,600.00
YMCA $450.00 65 $29,325.00
HOflle Care Before Age 21 $33,150.00 11 $364,650.00
Home Care After Age 21 $102,600.00 54 $5,540,400.00
Medications $1,693.96 65 $110,107.40
Physical Medicine until age 16 $360.00 6 $2,160.00
Physical Medicine $180.00 59 $10,620.00
Orthopedics until age 16 $640.00 6 $3,840.00
Orthopedics $160.00 59 $9,440.00
Ophthalmologist $60.00 65 $3,900.00
Urologist $60.00 65 $3,900.00
Primary Care $112.00 65 $7,280.00
X-rays until age 16 . $444.00 6 $2,664.00
X-rays $111.00 59 $6,549.00
EMG $688.00
Urodynamic Testing $2,000.00
Scooter $873.33 54 $47,159.82
Quad Cane $5.00 65 $325.00
Shower Chair $24.00 65 $1,560.00
Hand Held Shower $9.00 65 $585.00
Grab bars and shower mat $20.00 65 $1,300.00
Safety Aids! Adaptive Aids $50.00 65 $3,250.00
Raised Toilet Seat $20.00 65 $1,300.00
Bilateral AFO's until age 21 $2,086.00 11 $22,946.00
Bilateral AFO's $1,043.00 59 $61,537.00
Orthotic insole for shoe $65.00 65 $4,225.00
Software $250.00 65 $16,250.00
Transportation $164.41 59 $9,700.19
$0.00
$6,473,259.41
Residential Option
ITEM ANNUAL COST YEARS ONETIME/LIFETIME COSTS
. Physical Therapy Evaluations $121.00 65 $7,865.00
Occupational Therapy Evaluations $121.00 65 $7,865.00
Neuropsychological Evaluations $4,200.00
Physical Therapy $7,744.00 II $85,184.00
Occupational Therapy $7,744.00 II $85,184.00
Case Management $180.00 65 $1l,700.00
Behavioral Counseling $3,600.00
YMCA $450.00 65 $29,325.00
Home Care Before Age 21 $33,150.00 II $364,650.00
Community Residential Services $100,192.50 54 $5,410,395.00
Medications $1,693.96 65 $1l0,107.40
Physical Medicine until age 16 $360.00 6 $2,160.00
Physical Medicine $180.00 59 $10,620.00
Orthopedics until age 16 $640.00 6 $3,840.00
Orthopedics $160.00 59 $9,440.00
Ophthalmologist $60.00 65 $3,900.00
Urologist $60.00 65 $3,900.00
Primary Care $112.00 65 $7,280.00
X-rays until age 16 $444.00 6 $2,664.00
X-rays $111.00 59 $6,549.00
EMG $688.00
Urodynamic Testing $2,000.00
Scooter $873.33 54 $47,159.82
Bilateral AFO's until age 21 $2,086.00 II $22,946.00
Bilateral AFO's $1,043.00 59 $61,537.00
Orthotic insole for shoe $65.00 65 $4,225.00
Software $250.00 65 $16,250.00
$6,325,234.22
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SUSQUEHANNA REHABILITATION SERVICES
PO BOX 335
MECHANICSBURG, PA 17050
Federal Tax ID #: 23-257-4977
,
JJ/:;)C)/
INVOICE for
Professional Services
KARL ROMINGER, ESQUIRE
ROMINGER & BAYLEY LAW OFFICES
155 SOUTH HANOVER STREET
CARISLE, PA 17013
===============================================================================
Our Case Code : 2002-111
Client Name : BRINK, MATTHEW
Insured : N/A
Your Reference: N/A
-
Invoice No.: 979000102
Invc. Date: 11/17/02
Page Number: 1
Injury Date: 10/14/00
====================================================----------=================
Date
Description of Service Performed
Prof Tr/Wt M1g
other
-------------------------------------------------------------------------------
09/13/02 COPY OF MEDICALS @ $25/HOUR 0.50 0.00 0 50.30
09/16/02 RETAINER FEE/CHECK #1498 -1000.00
09/20/02 REVIEW MEDICAL RECORDS 4.00 0.00 0 0.00
09/26/02 VISIT CLIENT 2.00 0.00 0 0.00
09/26/02 TRAVEL 0.00 6.00 320 0.00
09/30/02 PC/PHYSICIAN 0.20 0.00 0 0.00
09/30/02 REVIEW MEDICAL RECORDS 0.50 0.00 0 0.00
11/01/02 PC/THERAPIST 0.20 0.00 0 3.96
11/01/02 PC/OTHER AGENCY/PROFESSIONAL 0.30 0.00 . - 0- 5.94
11/01/02 PC/OTHER AGENCY/PROFESSIONAL 0.30 0.00 0 5.94
11/01/02 PC/PHYSICIAN 0.30 0.00 0 5.94
11/01/02 PC/OTHER AGENCY/PROFESSIONAL 0.30 0.00 0 5.94
11/10/02 RESEARCH VIA INTERNET 1. 70 0.00 0_ 0.00
11/17/02 REPORT AND APPENDIX{S) 7.00 0.00 0 10.00
-
17 .30
6.00 320 -911.98
TOT A L S
-
-
Professional Hours ($125.00/Hr)
Travel/Wait Hours ($125.00/Hr)..
Mileage (0.390/Mi1e) .
Other fees . . . . . . .
GRAND TOTAL THIS INVOICE . . . .
2112.50
750.00
124.80
-911. 98
2075.32
_.
-------------------------------------------------------------------------------
Susqueh~nna ~ehabilitation 'Services
www,srsrehab.com PA. MD . DC · OH · VA · wv · DE · NJ . NY
Attention:
SRS Number:
Date of Referral:
Rominger and Bayley
Law Offices
155 South Hanover Street
Carlisle PA 17013
Karl Rominger
2002-111
9/11/02
To Account:
Date:
Plaintiff:
D.O.A.:
D.O.B.:
Disability:
March 10, 2003
Matthew Brink
10/14/00
12/31/91
Severe Traumatic Brain Injury
Right Hemiparesis
Multiple Orthopedic Trauma
Vocational Assessment
Introduction:
Susquehanna Rehabilitation Services has been requested to determine the loss of earning
capacity ofMr. Matthew Brink as a result of his accident on October 14, 2000. Matthew is an
11 year-old white male. who on October 14. 2000. was struck by an automobile while he was
riding his bicycle. Matthew sustained multiple traumatic injuries including a closed head
injury, hypoxic ischemic encephalopathy, right adrenal hemorrhage, aspiration pneumonitis,
liver laceration, right orbital fracture, right temporal bone fractures of the face, a right brachial
plexus injury, a right olecranon fracture, left tibial fracture, and an injury to the left lower ankle
including avulsed skin flap and tendon injury. Matthew has suffered right-sided hemiparesis as
well as loss of vision in the right eye due to an optic nerve injury. As a result of Matthew's
injuries and permanent physical limitations. he will experience a loss in future wages and fringe
benefits in the amount of$I.005,033.
This report will reflect Matthew's educational history and earnings loss as a result of the
automobile accident of October 14, 2000. In addition to my meeting with Matthew and his
parents, I have also been provided with the following documents in preparation of this report:
1. Matthew's school records from Shippensburg Area School District.
2. Life Care Plan dated November 17, 2002, by Valarie V. Parisi, RN, CRRN, LNC, CLCP
3. Records of Stephen Becker, M.D. from January ]5,2001 to March 11,2002.
4. Records from Milton S. Hershey Medical Center dated October 14, 2000 to September 13,
2002.
5. Police report from the Pennsylvania State Police dated October 14, 2000.
6. May 10,2002 report from Jessica Greenlee. M.S., P.T.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204 / E-Mail: srs@srsrehab.com
&hl b, t \18 II
. . '
Susquehanna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE · NJ · NY
Vocational Assessment
Re: Matthew Brink
March 10,2003
Page 2
Medical Status:
Matthew's medical treatment has been summarized in the life care plan written by
Valerie Parisi, R.N" CRRN, LNC, CLCP, and will not be repeated here. I had the opportunity
to meet with Matthew and his parents on February 6, 2003. At that time, Matthew was
occasionally experiencing severe tremors with his left arm. He had also suffered a right
brachial plexus injury. Matthew had limited movement with overhead reaching. Due to optic
nerve damage, he is unable to see out of his right eye. Matthew wears a right ankle brace and a
left foot-drop brace. Prior to this accident, his parents stated that he had no physical
complaints. However, the records reflect that Matthew did receive occupational therapy at
school to help with his writing and hand movements. The only prescription medication that is
taken is Aricept to increase brain function.
Educational Historv:
Matthew started his fonnal education in the Big Spring School District.' He attended the Head
Start program and on October 16, 1996, was tested by Alexander Spring Rehab, Inc. The
testing showed that Matthew's verbal and language skills were approximately one year below
his age at that time, 4 years and 9 months. It was recommended that Matthew receive speech
therapy one time per week through the head start program. Matthew was successful in reaching
his verbal goals through this program. but not the written goals. He was discharged on March
27, 1997. At that time it was recommended that he receive a complete speech and language
screening upon admission to Kindergarten.
An occupational therapy evaluation was completed on April 21, 1998. This was through the
Capital Area Intennediate Unit. There was a concern about Matthew's fine motor skills. The
Bruinisks-Oseretsky Test of Motor Proficiency and the Developmental Test of Visual-Motor
Integration were administered. Matthew was found to have normal postural tone. He was able
to run and gallop, but could not perform higher-level skills such as skipping and jumping jacks.
He held his pencil in a hooked wrist position and had difficulty with letter fonnation. As a
result of the testing, Matthew received in school occupational therapy.
On March 17, 1999, a comprehensive evaluation report (CER) was completed by the Big
Spring School District. Matthew had been administered the Kaufinan Brief Intelligence Test.
This showed his cognitive functioning to be within the average range with a vocabulary score
of 94, matrices score of 93 and full scale score of 93. This testing apparently had been
administered in January 1998 when Matthew was in Kindergarten. The Wechsler Intelligence
Scale for Children-Third Edition was administered for the CER. His verbal I.Q. was 80 and
perfonnance I.Q. 74. Matthew's full scale I.Q. was 75, which is mildly mentally retarded.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 3351 Mechanicsburg, PA 17050
Telephone: 800-836-3450 / Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
Susquehanna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE . NJ . NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 3
Matthew was found to have very poor math skills. He also took the Wechsler Individual
Achievement Test. This showed a listening comprehension score of 108, which was better than
expected. His reading, spelling and math abilities were below average. Matthew's parents
agreed with the Individualized Education Program (IEP), but disagreed with the cognitive
testing.
In September, 2000, Matthew started the third grade. According'to his father, Matthew was
held back for the first grade. This does not appear to be documented in any of the records that I
have reviewed. The IEP for the school year 1999-2000 was completed when Matthew was 8
years, 3 months old. He was in grade 2-8. which would be age appropriate.
The Woodcock-Johnson Achievement Test was administered on April 25, 2000. The grade
level results from this testing is as follows:
LetterIWord Identification: K.9
Passage Comprehension: 1.3
Dictation:' I. 5
Math Calculation:
Applied Problems:
Quantitative Concepts:
1.9
1.4
1.5
Matthew's math, speech and language skills were all improved. It was recommended that since
Matthew was functioning one year below his grade level that he received modifications in his
educational program through the learning support resource classroom. It was also
recommended that he receive the services of an occupational therapist 1-2 times per month to
assist him with his handwriting.
The Woodcock-Johnson Achievement Test was administered again on August 29, 2000. The
grade level results from this testing is as follows:
LetterIWord Identification:
Passage Comprehension:
Dictation:
Reading Instructional Level:
Grade Equivalent
K.8
1.4
1.5
PP-2
It does not appear that the other portions of this test were administered. According to the
records from Shippensburg Area School District, Matthew continued to make progress, but
remained significantly behind his peers. He was starting third grade at this time and had been
in learning support for language arts and math. He also received assistance with other class
work and studying for tests.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335/ Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. .
Susquehanna ~ehabilitation Services
www.srsrehab.comPA.MD · DC · OH · VA. WV · DE . NJ · NY
Vocational Assessment
Re: Matthew Brink
March 10,2003
Page 4
Matthew was involved in his accident on October 14, 2000. This disrupted his schooling and
accommodations were made with the school district to provide him with instruction outside of
the classroom.
At the beginning of the fourth grade, Matthew had another IEP completed, September, 2001.
The rep'ort outlines that Matthew had been receiving occupational therapy 1-2 times per week.
He was experiencing tremors with his left upper extremity and used his left hand to raise his
right arm. He was having difficulty with fine manual dexterity with his right hand. Matthew
was wheelchair bound and continued to have difficulty with concentration. Occupational
therapy and physical therapy were both recommended once per week. He was able to use age
appropriate speech and language, but had difficulty with saying more than 4 or 5 words at a
time. The Woodcock-Johnson Achievement Test was again administered on August 28, 2001.
The results are as follows:
LetterIWord Identification:
Passage Comprehension:
Calculation:
Applied Math:
Grade Equivalent
K.7
(No Basal)
1.4
K.O
Matthew was able to count by five's and ten's at a 50% accuracy rate. He was able to identity
basic coins by name and value about 50% of the time. This testing is significantly lower than
the testing completed prior to Matthew's accident. His math ability had not been tested in 18
months and one would expect improvement since the last formal testing. In April, 2000,
Matthew scored at almost the second grade. During the testing following the accident, he
scored at entry-level kindergarten. His passage comprehension score dropped to the grade 1.4
to not being able to be tested. Prior to the accident, Matthew had received specialized
instruction and had participated in some of the general education curriculum. The YEP
indicates that he is no longer cognitively able to do so.
Another YEP was completed on May 16,2002. The Woodcock-Johnson Tests of Achievement
were again administered. The results were as follows:
Letter-Word Identification:
Passage Comprehension:
Dictation:
Calculation:
Applied Problems:
Grade Equivalent
1.0
<1.0
1.5
1.9
1.1
Sensitive To Your Rehabilitation Needs
Horne Office: P.O. Box 335/ Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
Susq~eh~nna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE · NJ. NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 5
The test of word reading efficiency was also administered. The results of the sight word
efficiency and phonetic decoding efficiency places Matthew below the I" percentile. It was
recommended that Matthew receive speech/language therapy 30 minutes per week and
occupational therapy 30 minutes per week. Previously, Matthew had made enough progress
that it was not recommended that he be in the extended school year program. Unfortunately,
due to his regression and traumatic brain injury, the extended school year was found to be
necessary. His time of receiving special education outside of the regular education classroom
was increased to 61 % or more.
The last IEP evaluation in the materials is dated November 4,2002. At that time, Matthew was
receiving direct instruction in reading. written language, math and content subjects from the
learning support program. He was receiving speech and language support once a week. He
was also receiving occupational therapy and physical therapy once a week. In addition,
Matthew was receiving adaptive physical education. Due to the loss of vision in Matthew's
right eye, he had been receiving support services through the Capital Area Intermediate Unit.
This included adaptations in his placement in the classroom and size of print that he was given
to read. Matthew also had qualified for adaptive technology for use on the computer.
The principal of Matthew's school. Susan M. Martin, has sent correspondence to
Jeanette Ramer, M.D. regarding his progress in school. Most of the comments are behavioral
in nature instead of academic.
At the time of my meeting with Matthew he was eleven years old and in the 5th grade at Nancy
Grayson Elementary School in the Shippensburg Area School District. He was in learning
support for all classes, except for art and music. He was receiving speech therapy once a week
at school. He also was receiving occupational therapy and physical therapy once a week at
school. Matthew showed me his report card for the second marking period. He received C's in
reading, writing, spelling, and math. He received S's in art, vocal music, physical education
and library. It is important to keep in mind that these grades are not representative of
Matthew's performance based on the typical grading system. These are learning support
grades, as Matthew would not be able to pass these subjects in a regular classroom. In fact,
Matthew has not been able to make progress in the learning support environment and will enter
the life skills program next year. This will focus on teaching him how to cook, make change
and take care of himself This program continues through the l2'h grade. This program will
focus on job skills and provides a job coach in an attempt to assist the student in obtaining
some type of employment.
During my meeting with Matthew, 1 administered two tests. The Wide Range Achievement
Test. Revision 3, tan version and the Slosson Intelligence Test. Matthew was unable to spell
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204 / E-Mail: srs@srsrehab.com
Susq~eh~nna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA . wv · DE · NJ · NY
Vocational Assessment
Re: Matthew Brink
March 10. 2003
Page 6
his last name, he was unable to write the letter g or d. He wrote e, instead of g and was unable
to write any letter when asked to for the letter d. He was also unable to spell four out of the
first five words of the test. Matthew was able to spell cat, but not: go, boy, run or will. He
needed to use his fingers to perform basic arithmetic. He was unable to subtract I from 3, 3
from 9 or add 3 plus 4. Matthew was unable to read the letters u, v, and j. He pronounced the
word "was" as "saw". The results of this testing shows that Matthew is functioning at the
kindergarten level in reading, spelling and arithmetic. He is at the .02 percentile in reading and
arithmetic. He is at the .5 percentile in spelling. This means that 99.92 out of 100 children of
Matthew's age are able to function at a higher level than he is in reading and arithmetic. 99.5
out of 100 are able to function higher in spelling.
The results of the Slosson Intelligence Test shows that Matthew is currently functioning with a
Total Standard Score at the 95% confidence interval of between 39 and 53. This represents an
I.Q. of 53 on the Wechsler scale, someone who is moderately mentally handicapped.
The optimum determination of future earning capacity is to assess future educational
attainment. Weed (2000) explained that when one is trying to determine the earnings potential
of children, the vocational expert should consider the types of jobs that the parents or siblings
have held, and the child's potential educational attainment. Weed outlines that the child is
likely to gain a little more education than their parents, unless the parents are at the extremes of
the level of educational attainment, in that case. children seem to regress towards the mean.
Matthew's father, Tom Brink, graduated from high school in 1967 and took Ministry courses.
He was a Minister for 22 years. He also was a Journeyman Electrician. He has diabetes
mellitus, is legally blind. He also has had a stroke and several heart attacks. Mr. Brink has been
on disability since June 1995. Matthew's mother, Lisa Brink, graduated from high school in
1969 and has taken additional computer courses. She has worked for the newspaper in
Shippensburg as an Assistant Circulation Manager and Advertising Clerk. For the past four
years, Mrs. Brink has worked part-time as a Reporter and Photographer for the newspaper. She
also works 25 hours per week as a Clerk for the Newville Police Department. She is a
Community Service Officer, collecting money from parking meters, writing parking tickets,
completing data entry, filing and making telephone calls. At the time of Matthew's accident,
Mrs. Brink was employed as an Advertising Clerk for the newspaper working 20-25 hours per
week and making $6.50 per hour. She was unable to work from October 2000 to April 2001 as
she was taking care of Matthew.
Matthew has one brother and two sisters who have graduated from high school. Two sisters
did not complete their educations. One sister completed the 8th grade and another completed
the 9th grade. He has one brother who is still in school.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335/ Mechanicsburg, PA 17050
Telephone: 800-836-3450 / Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. .
Susquehanna ~ehabilitation Services
www.srsrehab.comPA.MD · DC · OH · VA · WV · DE . NJ · NY
Vocational Assessment
Re: Matthew Brink
March 10,2003
Page 7
Conclusions:
Matthew Brink was in learning support classes prior to the accident of October 14, 2000. He
was functioning at one grade level below his peers, but making progress. In 1998, the
Kaufman Brief, Mental Ability Test was administered which resulted in a verbal score of 94
and math score of 93. The composite score was 93. The report of Mark Haas, school
psychologist with Shippensburg Area School District indicates that a WISC- III test was
completed when Matthew was at the Big Spring School District, which gave him a full-scale
I.Q of 75. This would have placed Matthew's level of functioning in the mildly mentally
retarded range. There is no reference that this testing was repeated. This testing would have
taken place when Matthew was in the first grade at the latest.
Based on Matthew's home environment and the studies that have been published. it is possible
that he would have graduated from high school. However. based on his level of functioning
prior to the accident, I find it unlikely that he would have had the cognitive ability of the typical
high school graduate. Therefore, Matthew's future educational attainment pre-injury, is best
represented by someone who is not a high school graduate. Following the accident, all of the
testing areas have shown a significant reduction in Matthew's academic abilities. Even though
he is eleven years of age and in the fifth grade, he is functioning at the kindergarten level in all
academic areas. He is unable to write his last name or spell the most basic of words. The result
of the traumatic brain injury that Matthew suffered has reduced his I.Q. to 53. placing Matthew
in the moderately mentally handicapped range. In addition to these deficits, Matthew has lost
the vision in his right eye, has tremors in his left arm and limited range of motion of his right
arm. He also wears braces on both legs. The combination of these factors renders him disabled
from performing gainful employment. As these conditions are permanent. it is not anticipated
that Matthew's status will change.
The mean earnings ofa male, 16 to 24 years of age, without a high school diploma is $18,962.1
At the time of the accident, Matthew was 9.79 years of age. He would have a Worklife
expectancy, following his 18th birthday of 33.33 years.2 As a result of Kaczkowski v.
Bolubasz, future earnings are not to be reduced to present value.3 However. they can be
adjusted for increases attributed to productivity. The increase in earnings due to productivity
t Disability. Work Experience and Mean Eamings in 2000-Work Disability Status of Civilians 16 to 74 Years
Old, by Educational Attainment and Sex: 2002.. U.S. Census Bureau.
2 Worklife Estimates: Effects of Race and Educatiou. U.S. Department or Labor, Bureau of Labor Statistics,
February, 1986 Bulletin 2254., for all men with less than high school education.
3421 A.2d 1027, 491 Pa. 561 Kaczkowski v. Bolubasz, (pa. 1980)
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. . '
Susquehanna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE · NJ . NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 8
equals 1.3%.4 Matthew would also have the opportunity to earn fringe benefits while being
employed, These would equal 18.3% of his eamings.5
Proiected pre-iniurv eamines of Matthew Brink from aee 18 to Worklife expectancy
From To
-12/31/09 02112/43
Occupation
Laborer
Totals:
Annual
Eamines
$18.962
$849,566
Fringe
Benefits
$3.470
$155.467
Growth
Rate
1.3%
Matthew Brink's pre-IDjury earnings and fringe benefits, from age 18 to his Worklife
expectancy, age 52.12, equals: $1,005,033.
From a vocational perspective, his combination of reduced I.Q., loss of vision in his right eye
and multiple other physical impairments will preclude Matthew from sustaining competitive
gainful employment in the future, There is no offset to the amount that Matthew is projected to
have made over his lifetime,
The opinions contained in this report are within a reasonable degree of vocational certainty
based on the data that has been provided.
Sincerely,
Terry p, L~
Terry P. Leslie, M.Ed, CRC, ABVE, LPC
Vocational Counselor
Itpl
....
42002 OASDI Trustees Repon. U.S. Social Security Administration.
S Fringe Benefits informatiou from .'The 200 I Employee Beuefits Study"'. U.S. Chamber of Commerce, Statistics
and Research Center.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335/ Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
"'''"
* "-
"'"
HarleysVllle.
Good people to know
March 15,2002
Karl E. Rominger
Rominger Law Offices
155 South Hanover Street
Carlisle PA 17013
RE: Your client:
Our Insured
Claim #
Date/loss
Dear Mr. Rominger:
MidAtlantic Claims Service Center
Office Address Mailing Address
30B Harper Drive, Suite 200 P.O. Box 1016
Moorestown, NJ Moorestown, NJ
OB057-3245 06057-0916
(BBB) 595-9B76 Fax (B56) 642-1699
www.har1evsvilleqrouP.com
.- ..-'"
".---.~--
J_,~
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Matthew Brink, a minor
Lisa & Thomas Brink
MO 121711 WD
10/14/00
Be advised we do not wish to pursue subrogation in the above matter. Also, I am
enclosing as per your request, a certified copy of the policy relative to the above matter.
Should you need anything further, please advise.
SirtJ]~
Ann Pilla
Sr. Claims Specialist
1 8885959876 x 2346
Ex\')',bit "c."
RECEIPT RELEASE AND TRUST AGREEMENT
fOR AND IN CONSIDERA nON of the payment to melus, Lisa Brink and Thomas Brink, on behalf of Matthew Brink, a minor
of the sum of Sixty Thousand dollars ($60,000.00) by the HarleysvillelPennland Insurance Companies, the receipt of which is
hereby acknowledged, I1we do hereby fully release and forever discharge said Companies from any and all claims and causes of
action, which I1we now have or may have against said Company under the Uninsured Motorist I Under Insured Motorist provision
of Policy, No PAA 356429 resulting from an accident which occurred on the 14 day of October 2000 at Newburg PA.
I1we further agree in consideration of this settlement and payment pursuant thereto to perform and comply fully with ail the terms
and conditions of the aforementioned policy, indicating the trust agreement contained therein and incorporated in their release,
which is stated in the policy as follows:
Trust Agreement. In the event of payment to any person under this policy.
(a) the company shall be entitled to the extent of such payment to the proceeds of any settlement or judgment that may result
from the exercise of any rights of recovery of such person against any person or organization legally responsible for the
bodily injury and/or property damage;
(b) such person shall hold in trust for the benefit of the Company all rights of recovery which he shall have against such other
person or organization because of the damages which are the subject of claim made under this policy;
(c) such person shall do whatever is proper to secure and shall do nothing after loss to prejudice such rights;
(d) if requested in writing by the Company, such person shall take, through any representative designated by the Company,
such action as may be necessary or appropriate to recover such payment as damages from such other person or
organization, such action to be taken in the name of such person; in the event of a recovery., the Company shall be
reimbursed out of such recovery for expenses costs and attorney's fees incurred by it in connection therewith;
(e) such person shall execute and deliver to the Company such instruments and papers as may be appropriate to secure the
rights and obligations of such person and the Company established by this provision.
I1we further state that I1we have carefully read the foregoing release and trust agreement and know the contents hereof, and I1we
signed the same as my{our own free act.
WITNESS my/our hand and seal this
Jvr)
day of_-
llf' . I'
t f/V"; I
') ....,
/ QC...s
, .~.
Signed in the presence of
1_ ft..
!\C;J (, $~C. '\.I, (;~} {/,..
/
/.:;::..../-.
}
}
}
}
}
}
}
CAUTION READ BEFORE SIGNING
~ " \ 1
dt~.(d), \'A:~-S" h!\~..\ J
; r /'1"';> .4~~
(Seal)
(Seal)
State of
)
)
}
}
)
County of
_. ") rd /)
On this _ ~ day of r' (1t'
"
,.1./5)1 /7 Ck~jl-'k:' -and 7/;'::-0).,;.5 J.)>"./O e to know to be the
person described herein, and who executed the foregoing instrument and who acknowledged that voluntarily executed the same.
'1 /,J,;C n:,lX t ___
,
"
i":~(~O before me personally appeared
My term expires
'--/" './
".","../ <>., c/.",:r
1 ' Nc~r.al SoaINOlary PUOll1
UAda.1. Jumper, Not""! Pubf"
GaI1isle Boro, Cumberland Coonty
My ComrriSsion E>q::ires J(jy 23. 2006
(If this release is acknowledged before a ~~~ij!~ are neces'ary)
./,;,;'_ /1 ~f ./i{"
(C-498 12/98)
Claim # MO 121711 WD
E)(hibi t "~,.
.
Berkshire Mutual Insurance Company
Great Oaks Insurance Company
Harleysville-At1antic Insurance Company
Harleysville-Garden State Insurance Company
Hsrleysvil1e Insurance Company of New Jersey
Harleysville Mutual Insurance Company
Huron Insurance Company
Mainland Insurance Company
Mid-America Insurance Company
Penn land Insurance Company
Worcester Insurance Company
LETTER OF CERTIFICATION
Ann Pilla
Mid-Atlantic Claims Service Center
This is to certify that the attached is a true and correct copy of:
Personal Auto #PAA-356429, all policy tenus from 06/04/00 to 06/04/01,
January 24, 2002
insofar as it relates to the insurance afforded thereunder at the following location:
275 Newburg Rd. Newburg, PA 17240, to the Named Insured: Lisa A Brink,
on the date of the loss 10/14/00, and purchased in Pennsylvania.
~")(.~\bit \If-,I
~~
Susan Erney-Skelton
Assistant Vice- President
PAGE III ISSUE il/0l/01l G'i
KGa I
PAA 35 &4 29
AMEHOED
PERSONAL AUTO POLICY DECLARATIONS
PENNLANO INSURANCE CONPAHY
NARLEYSVILLE PA 19~3a
PAA 35 6~ 29
DIRECT BILL
LISA A BRIHK
275 H[WBUAG RD
NEWBURG PA 172~0
BEL"OHT BRANDT I KNOLL I"C TIA
D"H" IR"HDT JHSUR"HCE
27 B BECONO BT
NEWPORT PA 1707~
10-11-00 7l-75~2
AGEHT TELEPHOHE:717-567-6060
0&-04-00 TO 06-04-01
ORIGIHAL POLICY DATE 06/99
PREFERRED
YOUR PGLICY HAS BEEN CHAHGED IN THE FOLLOWING "ANNER
CHAHGE IN POLICY INFORNATION
................. IASIC COVERAGES .................
THE COVERAGES BELOW ARE PROVIDED FOR VEHICLES WHERE A PRENIU" IB CHARGED
OR THE WORD IHCLUOED IS DISPLAYED.
PRE"IUNS FOR VEHICLE I
---11--- ---12--- ---13--- ---I~---
LINITEO TORT OPTION 6ELECTED.
HO EXTRAOROIHARY HEQJCAL EXPENSE BEHEFITB COVERAGE BELECTED
--------LINITS-------- S9 PLYN SI CHEY S7 CHRY S~ PLY"
. 25.000 EACH PERSON
. 50.000 EACH ACCIDEHT .
. 25.000 EACH ACCIDEHT .
-COVERAGE-
SODILY IHJURY
PROPERTY OANAGE
UNINSURED NOTORIST
UNSTACKED . 15.010 EACH PERSOH
. 30.000 EACH ACCIOEHT' 19.00' I~.OO' I~.OO' I~.OO
UNOERINSURED NOTORIST
UHSTACKED . 15,010 EACH PERSCH
. 30.000 EACH ACCIDEHT. 13.00' 10.00 I 10.10 I 10.00
FIRST PARTY BENEFITS-EACH PERSON -PP0551. 2~.00' 2~.00' 2S.IO' 103.00
NEDICAL EXPENSES . 5.000 IHCLUDED INCLUDED INCLUDED INCLUDED
WORK LOSS NDIIE
ACCIOEHTAL DEATH NOHE
FU"EAAL "OHE
-COVERAGE FOR OANAGE TO YOUR AUTO
OTHER THAN COLLIBION . 500 DEDUCTIBLE . I~.IO
TOWIHG I 50 EACH DIBABLE"EHT I 5.00
COLLISION . 500 DEDUCTIBLE I 63.01
RENTAL REI"SURSENEHT liS PER DAY/I~5S TOTAL INCLUDED
REVISED PER VEHICLE TOTIL . 261.IS I 171.01 I 25~.II I 6~7.I1
VEHICLE PRE"IUN AOJUSTNEHT FDA CHANGE . 59.11
...................................................
REVIlED TOTIL POliCY PREIIIUII I 1333.01
POLICY PRENIU" IDJUBTIlEHT FDA CllIHGE I 59.01
...............................~"..................
73.10 I 73.10 I 121.00 I 30S.00
50.10 I 51.00 I B2.00 I 212.10
PIGE II IIBUE 11111111 ll'I I
Lla
PREV FICHE ID 12a5-007N09
PRIOR TERM ID
LAST TRINS: CHANGE ON POLICY
DATE RECD 11/31/00 ENTRY DATE 11/01/00
CURREHT-ICTIVE IREHEWALI
CYCLE 11111/01
PRIOR BTATUB 01
IHTERFACEO
LAST CHO DT lOllI/DO LAST PRE" CHG OT 10/11/00
SDIP OT 06199
PREF EHTER:060~IO
TIER-QUALIFY F, T1ER-EHTER Ff
OVERIDES :
&UI CLASS PREP DATE 04/14/00
OWNED
.FED-E"P
-RATE ISSUE DATES.- ... STAT IHFO ....
VEHl VEH2 VEH3 VEH~ SUBL PER ACC STEXC
990a 991a 9916 990a SOL 05 10 5
990a 990a 990a 9906 502 05
990a 990a 990a 990a 505 13 06 6
990a 9906 990B 990B 520 06 5
991a
HOB
Hoa
530
531
530
722
077
71'
PER POLaST 37,TERR 027CAHCELLATI0" FACTOR: .74
.... LIJ(;l _
P" 35 6~ 29
06-0~-00 TO 06-04-01
10-11-00
.................... MESSAGES .....................
YOUR POLICY HAS 8EEH OISCOUHTED 051 TO REFLECT VOUR DRIVIHG RECDRD
HARHIHG HOTICE' AMY PERSOH HHO KHOHIHGLV AHO NITH IHTEHT TO DEFRAUD AMY
IHSURAHCE COHPAMY OR OTHER PERSOH FILES AH APPLICATIOH FOR IHSURAHCE OR
STATEHEHT OF CLAIH COHTAIHIHG AMY HATERIALLV FALSE IHFORRATIOH OR COHCEALS FOR
THE PURPOSE OF HISLEAOIHG. IHFORHATIOH COHCERHIHG AMY FACT MATERIAL THERETO
CO"HITS A FRAUOULEHT IHSURAHCE ACT. HHICH IS A CRIHE AHO SUBJECT8 THE PERSOH
TO CRIHIHAL AHD CIVIL PERALTIES.
.............. VEHICLE DESCRIPTIOHS ...............
VEHICLE
A VR OESCRIPTIOH VEH 10 HUHBER TERR CLASS OR X OR X OR X OR X
1 89 PLVH HAG 4K2 IP4FH5~3SKK639060 PA-027 81112H 1-100
SVH 08 FACTORS .70
2 81 CHEVRPU IGCCCI405BBI18401 PA-027 81112H 1-100
SV" II FACTORS .70
3 87 CHRY COUPE 2D 3C3CJ41K5HT734413 PA-027 884L2H 3-100
SV" 10 FACTORS 1.15
4 64 PLYHOSDH 3246136848KKKlOOOl PA-027 871D2" 2-100
SV" 07 FACTORS 2.15
... ADDITIOHAL VEHICLE IHFORHATIOH AHD DISCOUNTS ..
"*THE FOLLOWIHG IHFORhATIOH APPLIES TO IHDICATED VEHICLE HUHBERS.
II ORIVEH, FOR PLEA6URE OR LESS THAH 3 "ILE8 TO HORK 00012 AHHUAL "ILES
HULTI-CAR DISCOUHT -251
'2 ORIVEH: FOR PLEASURE OR LESS THAH 3 "ILES TO HORK 00012 AHHUAL "ILES
HULTI-CAR DISCOUHT -251
'3 ORIVEH: FOR PLEASURE OR LESS THAH 3 "ILES TO HORK 12000 AHHUAL "ILES
"ULTI-CAR OISCOUHT -25X
PASSIVE RESTR"HT OISCOUHT -30X OH FIRST PARTY BEHEFITS
HOH-"OTORIZEO RESTRAIHT COVERAGE
.~ DRIVEH: FOR PLEASURE OR LESI THAH 3 MILES TO WORK 12000 AHHUAL HILES
HULTI-CAR DISCOUNT -251
............... DRIVER IHFOR~TIOH ................
...THE FOLLOHIHG HILL OPERATE VEHICLES COVERED IV THIS POLICY.
. STATE BIRTH "ARITAL L1C
DRIVER ST LICE"SE . DATE P/O SEX STATUS DATE
I LISA BRIHK PA Z1184805 02/01/51 P F " OZ/67
2 KEHHETH 8RIHK PA 26647397 12/28/83 P " S 07100
3 THOHAS 8RIHK PA 24865497 08/27176 P " S 09192
... POLICYHOLDER HOTICES AHD POLICY IHFOA",TIOH ...
'22"'0296 '21940894
lLOS100181 A17491284
A20750692 PPI3011211
Z8871291 29090316
A20790392
ST71710695
..9620111
1119620799
PAGE 02 ISSUE 11/01/00 G4 I
"08 I
PAA 35 04 21
06-04-00 TO 06-04-01
10-11-00
...... POLICY EHDORSEMENTS AND POLICY FORNI .......
PJ0006E08S5 PPI4211615 PPI4211710 PPI4171615 PPl4160710 PP03360710
PP05510614 PPOl510817 PPOOOI0614 PR01060614 PP03030411 PP03050886
A22300315 PP03010411
.............. lOSS PAYEE 1 ADDITIONAL I"IURED ..................
-LOSO PAVEE- VEHICLES. I
'HERICAH GEHERAL FIHAHCE
1201 CARLISLE RD
VORK PA 17404
............. EHD OF POLICY DECLARATIONS ..........
PREV FICHE 10 02S5-007"09
PRIOR TER" 10
TIER ............. STAT ............. IHYALID
EXCPT TIER CLASS HULT PRF VI" WI" OT
I S1112" 00/00
1 81112" O~/OO
1 884L2M 00/00
USE AHTI
CHG DT THFT
04/14/00 I
04/14/00 I
04/14/00
11111/00
----HVR---
STAT DATE
00/00/00
00/00/00
00/00/00
67102H
00/00
PASS AHTI OEF O~Y --DPR--DATE
REST lOCK DRV L~"P LIC OT ADDED
5 1 9 10/01/99
5 9 10/2S/99
3
9
5
S
---OTC----
STAT DATE
-Aev OTC--
STAT DATE
00/00/00
00100100
00/00/00
PREV FICHE 10 0285-007H09
PRIOR TER" ID
03/30/00
lO/11/oo
--OATE--
ADDEO
06/04/99
07125100
10/11/00
~&~
LAW OFFICES
KARL E. ROMINGER, Esq.
MARK F. BAYLEY, ESQ.
lSS SOUTH HANOVER STREET
CARLISLE, PENNSYLVANIA 17013
TEL: 717.241.6070
FAX: 717.241.6878
laW@romingerlaw.com
www.romingerlaw.com
March 29, 2002
RE: OUR CLIENT: MATTHEW BRINK, a minor
YOUR fNSURED: Lisa and Thomas Brink
CLAIM NUMBER: MO 121711 WD
DATE OF LOSS: 10/14/00
~
~
~.
Ann Pilla
Sr. Claims Specialist
Harleysville Insurance
P.O. Box 1016
Moorestown, NJ 08057-0916
Dear Ann:
I am in receipt of your March 15, 2002 letter and the certified copy of the policy. We
appreciate a.ll of your efforts in this matter.
I have reviewed the packet which you provided me with, and I note that while my client
opted not to carry uninsured/underinsured coverage in 1997, that she did opt to carry the same in
1999 and did not waive stacking. Therefore, the policy printout as it now displays unstacked is
most likely incorrect.
It is therefore our position that the applicable policy limit for uninsuredlunderinsured is
15,000/30,000 with stacking for each vehicle owned at the time of the accident. I believe that the
Brinks had five (5) vehicles at the time ofthe accident, although it could have possibly been
four (4).
You indicated that you would be seeing if there were any other sign downs. If there are,
please call them to my attention immediately. Otherwise, I will look for your confirmation
indicating that there is in fact stacked coverage available, along with your company's position on
how many vehicles the Brinks owned in October of2000, which would be the basis for a
multiplier of this coverage.
E)C.hibit "E 1"
ADVOCACY ADVICE ANSWERS
Ann Pilla
Sr. Claims Specialist
2
March 29, 2002
Finally, I would ask that you state whether or not you would waive subrogation, given the
increased coverage applicable, and give consent to settle at our discretion.
Sincerely,
-~
,
/,,/' ~~-----
-
---
Karl E. Rominger, Esquire
KER:ljj
cc. Mr. and Mrs. Thomas Brink
"'''"
'1< ~
...
HarleysvIlle,.
Good people to know
MidAtlantic Claims Service' Center
Office Address Melling Address
308 Harper Drive, Suite 200 P.O. Box 1016
Moorestown, NJ Moorestown, NJ
08057-3245 08057-0916
riP
1-/ /11 J t 7/
(888) 595-9876 Fax (856) 642-1699
www.harlevsvillearouD.com
April 9, 2002
Karl E. Rominger
Rominger Law Offices
155 South Hanover Street
Carlisle PA 17013
RE: Your client:
Our Insured
Claim #
Date/loss
Matthew Brink, a minor
Lisa & Thomas Brink
MO 121711 WD
10/14/00
Dear Mr. Rominger:
This will serve to acknowledge your letter of March 29, 2002. Be advised
I have referred this matter to our Home Office for further review. I will contact
you shortly concerning our position regarding coverage once a decision has
been reached.-
Sincn. fla
Ann Pilla
Sr. Claims Specialist
1 888 595 9876 x 2346
E.x.hibit \If 1."
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATI'HEW BRINK, a minor
No.
AFFIDAVIT OF CONSENT
AND NOW, comes Tom and Lisa Brink, parents of Matthew Brink, DaB: December 31,
1991, and requests that the Cumberland County Court of Common Pleas grant the Petition for
Leave of Court to Settle and Compromise Minor's Oaim. This request is made as the parent
and legal guardian of Matthew.
Date:
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c:;,)~ I'~~
Li~Brink Ij ~
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Date:
I (;:).c~ 1 CL:>
Tom Brink
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IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK, a minor
No. 0 3 - j" '1 '3
PETITION FOR LEAVE OF COURT
TO SETTLE AND COMPROMISE MINOR'S CLAIM
Pursuant to Pa. R.C.P. No. 2039(a), Petitioners, by and through their attorney,
Karl E. Rominger, Esquire, petitions this Honorable Court for leave to settle and
compromise the uninsured/underinsured personal injury claim of Matthew Brink, a
minor, and in support thereof avers as follows:
1. Petitioners are Tom and Lisa Brink, the natural parents of Matthew Brink, a
mmor.
2. Petitioners Tom and Lisa Brink and their son reside at 75 Newburg Road,
Newburg, Cumberland County, Pennsylvania.
3. The minor child, Matthew Brink, was born on December 31, 1991, and is 12
years of age.
4. On or about October 10, 2000, the minor child, Matthew Brink, was struck by
a motor vehicle while riding his bicycle in Newburg, Cumberland County, Pennsylvania,
outside of his home.
5. Matthew suffered traumatic injuries, including closed head trauma, loss of use
of an eye, and numerous other debilitating conditions which are more fully described in
the Life Care Plan attached as Exhibit. A..
6. As a result of the closed head trauma, Matthew has also suffered a loss of
faculties and mental capacity which is more fully described in Exhibit "B", Vocational
Assessment.
7. The child's parents have endured great financial expense, and the child's
mother missed at least one (1) year of work immediately after the accident.
8. Tom and Lisa Brink need the reliable transportation ofa handicapped
accessible minivan to make transporting Matthew to and from the family easier and more
comfortable.
9. There is and has been extensive work ongoing in regards to a third party
tortfeaser action against the driver of the vehicle and other responsible individuals. The
parents and counsel are actively pursuing over one (I) million dollars in other coverage.
10. Harleysville Insurance is a corporation located at P. O. Box 10 16
Moorestown, New Jersey 08057-0916 and by and through its' representative, Ann Pilla
has offered to tender a settlement at the Policy Number: PAA356429 which belongs to
the guardians of said minor and covers under its' uninsuredlunderinsured portions said
mmor.
II. However, at this juncture, Harleysville Insurance which is the first party
carrier for Tom and Lisa Brink, have agreed to settle for their policy limit and have
waived their subrogation rights (See Exhibits "C" and "D").
12. Originally, Harleysville Insurance took the position that the policy limit was
$15,000.00, but undersigned counsel was able to show, after careful examination of the
relevant records, that the stacking options of the policy was not properly waived and that
the applicable limit was thus $60,000.00 given the four (4) vehicles owned by the Brinks.
Exhibit "E."
13. It is proposed that the $60,000.00 once received be distributed as follows:
(a) Twenty-seven (27%) percent as a fee pursuant to a fee agreement
signed with Rominger & Bayley to the Law Firm of Rominger & Bayley;
(b) Fifteen Thousand ($15,000.00) Dollars paid directly to the parents for
the care and upkeep of the minor child, including the purchase of a used
minivan which would have better handicapped access than the current
automobile owned by the parents;
(c) Ten Thousand ($10,000.00) Dollars to be used by the attorneys for the
guardian of the child for expert expenses past and present, including any
and all litigation expenses which may have accrued or accrue in the
furtherance of the litigation against the third party tort feaser; and
(d) The remaining balance of the Sixty Thousand ($60,000.00) Dollars to
be placed in an account which is federally insured and interest bearing and
to be held until Order of Court and otherwise managed in accordance with
the Rules of Civil Procedure.
14. Petitioners believe and therefore aver that a settlement and distribution of
funds for the minor is fair and just and should be approved by the Honorable Court and
have executed an Affidavit of Consent which is attached hereto and made part hereof and
identified as Exhibit "F."
15. This Petition for Leave of Court to settle and compromise a minor's claim is
based only upon the uninsured/underinsured portion of the first party benefits available
and is no way intended by the parties to set a value for any underlying action, nor to limit
in any way any underling action against any third parties and is solely a compromise and
settlement between the first party benefit provider and the minor, Matthew Brink and his
parents.
WHEREFORE, Petitioner prays that this Court approve the above-described settlement
proposed on behalf of the minor child.
Respectfully submitted,
Date: J;fr < ~ IJj03
:2 '
,
~ ---
I E. Rominger, Esquire
155 South Hanover Street
Carlisle, PA 17013
(717) 241-6070
Supreme Court ill # 81924
Attorney for Petitioner
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MAIIH};W BRINK, a minor
No.
CERTIFICATE OF SERVICE
I, Karl E. Rominger, Esquire, attorney for Tom and Lisa Brink, do hereby certifY that I
this day served a copy of the Petition for Leave of Courl to Settle and Compromise Minor's
Qaim upon the following by depositing same in the United States mail, postage prepaid, at
Carlisle, Pennsylvania, addressed as follows:
Harleysville Insurance
Ann Pilla, Claims Representative
P.O. Box 1016
Moorestown, New Jersey 08057-0916
Dated: )017 21 2 ifJ5
2RD~'
Attorney for Petitioner
" I
'Susquehanna ;e>ehabilitaHon Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE . NJ' NY
To Account:
Rominger and Bayley
Law Offices
155 South Hanover Street
Carlisle PA 17013
Karl Rominger
2002-111
9/1 1102
Attention:
SRS Number:
Date of Referral:
Date:
Client:
D.O.!.:
D.O.B.:
Disability:
November 17,2002
Matthew Brink
10/14/00
12/31/91
Severe Traumatic Brain Injury
Right Hemiparesis
Multiple Orthopedic Trauma
Life Care Plan
Introduction:
Matthew Brink is a 10 year old male referred by you for the purpose of developing a Life Care
Plan to address the medical and non-medical disability lifetime needs and costs associated with
his disabling conditions secondary to a motor vehicle accident on 10/14/00.
A Life Care Plan is a comprehensive report which addresses the medical and non-medical
needs as a consequence of a catastrophic injury which projects the costs of needed items and
services over the person's anticipated life. This Life Care Plan is specific to the individual and
is not generalized to a particular disability.
Matthew Brink sustained multiple injuries including a severe closed head injury, hypoxic
ischemic encephalopathy, right adrenal hemorrhage, aspiration pneumonitis, .Iiver laceration,
right orbital fracture, and right temporal bone fractures of the face, a right brachial plexus
injury, a right olecranon fracture, left tibial fracture, and injury to the left lower ankle including
avulsed skin flap and tendon injury. He has right sided hemiparesis as well as visual
impainnents on the right side due to optic nerve injury.
This Life Care Plan was prepared by a review of the medical records provided, a nursing
assessment visit to Matthew Brink on 9/26/02 at his home, and consultation with local
provider's offices and resources.
Records Reviewed:
1. Reports of Dr. Jeanette Ramer, Developmental Pediatrician, Hershey Medical Center.
2. Report of Pediatric Orthopedic Clinic, Hershey Medical Center.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
E)(h i bi-l "A'.
Sl1sq~eh~nna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA . WV · DE · NJ · NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 2
-
3. Reports of Hershey Medical Center, inpatient and outpatient records.
4. Accident Report, 10/14/00.
5. Newburg Ambulance Records.
6. Records of Dr. Stephen Becker, Primary Care.
7. Report of Dr. Bonsall, Ophthalmology.
8. Records of Shipp ens burg Area School District.
9. Records of Chambersburg Hospital.
Medical Summary:
The information contained within this medical history was taken directly from a review of the
available medical records.
10/14/00-11/6/00 Admission Hershey Medical Center
Diagnoses: Closed head injury. Hypoxic ischemic encephalopathy. Liver laceration. Right
adrenal hemorrhage. Aspiration pneumonitis. Open left ankle fracture. Left femur fracture. Left
tibia- fibula. fracture.
Operations/Procedures: Placement of subarachnoid intracranial pressure monitoring bolt.
External fixation of the left tibia- fibula fracture. Incision and drainage of the left ankle.
Mechanical ventilation.
Hospital course: Matthew is an 8 year old boy who was struck by a motor vehicle while riding
his bike on the day of admission. There was positive loss of consciousness and he was down for
25 minutes. Upon arrival of EMS he was reported to have agonal respirations. He was
pharmacologically paralyzed but repeated intubation attempts failed. Upon arrival to the
Trauma Bay, the patient was noted to be unresponsive with a Glasgow Coma Scale of 3 with
hemodynamic instability. Trauma resuscitation protocols were followed and multiple blood
products including red blood cells and fresh frozen plasma were infused. The patients'
orthopedic injuries to his left lower extremity were addressed on Day #1 and the placement of
an ICP bolt was also performed. CelVical spine precautions were followed and his
hemodynamics were monitored. A Dopamine drip was started to maintain kidney perfusion on
Day #1. The patient's neurological status remained unchanged. There was no incidence of
intra-abdominal bleeding from the patient's documented liver laceration. IV steroids were
started for optic nelVe injury. On hospital day #6 he was started on parenteral nutrition. Enteral
nutrition was then begun as tolerated. The patient's respiratory status was monitored for
aspiration pneumonitis and antibiotics were instituted. The patient was extubated five days
prior to transfer to rehab. He remained unresponsive with no vocalization. He remained on
antibiotics for positive tracheal aspirate cultures and positive blood cultures for staph infection.
He was discharged to rehab on IV antibiotics.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-3450 I Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. .
. Susquehanna ~ehabilitation Services
www.srsrehab.comPA.MD · DC . OH · VA. WV · DE . NJ · NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 3
11/6/00-12/21/00 Admission Hershey Medical Center Rehabilitation Unit
Final diagnosis: Severe closed head injury. Right hemiparesis.
History of present illness: He was riding a bike and was hit by a car. There was a 25 minute
gap without care. When the emergency crew arrived he had agonal respirations. There was a
failed intubation at the time. His Glasgow Coma Score was 3 upon arrival to the ER. He had
decreased blood pressure requiring fluid resuscitation. Injuries included a severe closed head
injury. CT scan showed a small right occipital intraventricular hemorrhage, a right orbital
fracture, and right temporal bone fracture with pneumocephalus. He also had a left open
tibiofibular fracture, a right supracondylar fracture, and a right shoulder injury.
Complications in the acute setting included difficulty with ventilation, pneumonia, and
pulmonary edema. He failed extubation on the first try due to these problems. He was
successfully extubated on 10/31, but required oxygen until he was discharged to rehabilitation.
At the time of transfer he had become more reactive with spontaneous movements, the left
more than the right. He opened his eyes spontaneously, grimaced to discomfort, and had
semipurpo.seful movements of his left arm. There were no vocalizations.
Past medical history: Mild asthma. No other medical problems. He was described as a
hyperactive risk taking child. He attended third grade in the learning support placement.
Hospital course: Feedings were advanced to oral feedings. He had persistent right hemiparesis
with arm affected more than his leg. He also had facial weakness on the right side. He had
emergence of language 10 days prior to discharge. He began to use short phases and his
answers were accurate and clear. He had difficulty with word retrieval. He has significantly
impaired vision on the right. His functional motor skills improved and he was able to roll in
bed, get from sidelying to sitting with contact guard, sit in his wheelchair without assistance
and transition to standing. He could stand with one hand held for ten minutes. He had re-
emergence of allergies and was placed on Claritin.
Condition on discharge: Return to brain injury clinic. Therapies in the community 2-3 times
per week. He will be receiving homebound services from school.
1/4/01 Dr. Segal- Pediatric Orthopedics
Over the course of his rehabilitation stay, a brachial plexus palsy on the right side was
determined. He has also developed bilateral equinus contractures. He is using his hand more on
the right side. A short leg cast was removed today from his tibia. X-rays reveal t he fracture of
the left tibia is healed, but in 10 degrees of varus. He has bilateral equinus contractures of 10-
15 degrees. Radiographs of the right elbow reveal the olecranon fracture to be healed and the
radial neck fracture to be healed. The small decubitus under his left heel has completely
resolved. He will be seen for removal of right elbow hardware and to address his equinus
contracture with heel cord lengthening. He is to have BoTox injections in the interim.
Sensitive To Your Rehabilitation Needs
Home Office: r.o. Box 335/ Mechanicsburg, PA 17050
Telephone: 800-836-3450 / Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. Susqueh~nna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE . NJ. NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 4
1/23/01 Dr Ramer- Developmental Pediatrician
He has had some progress in skills. Motor skills have shown improvement. Language is
improving more slowly. He was assessed by the therapy team today. Current areas of concern
include attention focus which is only 3-5 minutes for homebound instruction. He is incontinent
of urine, but not of stool. He has a recent sinus infection which was treated with Augmentin. He
had some wheezing this weekend and used an old inhaler with good results. He is tolerating
therapies and is ready to give up the wheelchair. He can walk with assistance at this point. He
still uses short phrases and has difficulty with word retrieval. Right hemiparesis remains
evident. He has a resolving hematoma on the occipital portion of his head. He also has an area
of imbedded glass in the abdomen which should work its way out. He will be entering the
Franklin Learning Center for school based therapies and learning support. He is to wean off
Zoloft.
2/1/01 Dr. Segal- Pediatric Orthopedics
He sustained multiple injuries including a severe closed head injury, a right brachial plexus
injury, a right olecranon fracture, left tibi!l1 fracture, and injury to the left lower ankle including
avulsed skjn flap and tendon injury. Underwent placement of an external fixator of his left
tibia. Underwent open reduction internal fixation with tension band wiring of his right
olecranon fracture as well as a non displaced right radial neck fracture. He has also developed
bilateral equinus contractures. The tibial fracture was healing well clinically, however it has
healed with 10 degrees of varus defonnity. He was also noted to have bilateral equinus
contractures 10-15 degrees. He is to continue with physical therapy, progressive weightbearing,
and consider BoTox injections in his triceps to see if one could avoid heel cord lengthening. He
has been using a walker for one month.
Radiographs: Stress radiographs with varus and valgus stress of the tibia, which showed some
motion at this site.
We have tentatively scheduled the patient for future procedures, including removal of hardware
from his right elbow and addressing his equinus contractures.
Recommendations: Under one anesthetic, we can consider bilateral heel cord lengthenings,
removal of the hardware from his right elbow, and addressing his nonunion varus deformity
with open reduction and internal fixation with iliac crest bone grafting. He has been placed in a
short leg cast for stability and will continue PT.
3/8/01 Pediatric Orthopedics
Impression: He is scheduled to have hardware removal of his right olecranon fracture, bilateral
heel cord lengthenings for equinus contractures, and correction of the left tibial nonunion with
iliac crest bone grafting. He has been tolerating his short leg cast.
Plan: Obtain x-rays of his right shoulder and x-ray of the tibia out of the cast.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. Susquehanna ~ehabilitation Services
www.srsrehab.com
~.~.OC.OO.~.~.ill.~.m
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 5
3/27/01 Dr. Ramer- Developmental Pediatrician
He is on Bonine for nausea. He is taking Sudafed and Flonase for congestion. His biggest
problem is recurrent sinusitis. He is receiving PT. OT and speech at the Franklin Learning
Center. Speech clarity remains poor. He become fiustrated and angry. He will calm down if
sent to his room. He has shaking of his left arm and this makes it difficult to self feed and his
parents have to intervene. This makes him angry. He also has tremor with writing. He has
balance issues but is walking well.
Impression: Ongoing issues are recurring sinusitis, non union of the left tibia, and continued
deficits in learning. He is to have an ENT referral. This could be related to his facial fractures.
5/9/01-5/11/01 Admission Hershey Medical Center
Admission diagnoses: Left tibial non-union. Right olecranon hardware.
Procedures: Open reduction and internal fixation of left tibial non-union. Hardware removal of
right olecranon.
Hospital course: He underwent the above procedures without complications. He progressed to
physical therapy.
Discharge, instructions: He will continue routine cast care and remain non weight bearing left
side. To use crutches or walker for ambulation. He will continue elbow range of motion
exercises at home.
5/24101 Pediatric Orthopedics
Now returns two weeks post removal of hardware from right olecranon and left tibial
osteotomy for varus defonnity. He has been tolerating his long leg cast. Sutures were removed.
X-rays show interval healing of the tibial osteotomy site. The tibia is healed in slight valgus. He
will have his cast shortened.
6/21/01 Pediatric Orthopedics
He underwent left tibial osteotomy for non-union. He is wearing his long leg cast. He is using
his right upper extremity more. X-rays reveal interval healing. There is a gap noted at the
osteotomy site which is in 7 degrees of valgus.
Plan: Continue PT. Long leg cast changed to short leg cast.
6/26/01 Dr. Ramer- Developmental Pediatrician
He is receiving PT, OT, and speech at school. He is having difficulties with concentration and
attention. The tremor in his left arm is less visible. He is able to feed himself unless he is eating
soup. He can drink from a soda bottle without too much spillage. His right ann is still weak. He
has a cast on his left leg due to non-union left leg. He has poor judgment and memory issues.
He has a scanning quality to his speech and interrupts. His answers are not well organized.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
. ,
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www.srsrehab.comPA.MD.DC.OH.VA.WV.DE . NJ . NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 6
Impression: Significant motor and cognitive impairments. He is receiving appropriate school
and therapy services. Additional PT may be needed.
7/23/01 Pediatric Orthopedics
He is 2 Y, months post left tibia osteotomy. He underwent compression plate fixation of the left
tibia osteotomy as well as removal of the hardware from his right elbow. He is still not moving
his right shoulder. He has been compliant with non weight bearing left leg. X-rays of the tibia
reveal a gap at the osteotomy site with no distinct evidence of healing.
Plan: Repeat x-rays. Discontinue cast and give Cam Walker. EMG for right brachial plexus.
PT for non weight bearing at school.
9/6/01 Pediatric Orthopedics
He is four months post left midtibial osteotomy. He is using a Cam walker. He is still having
weakness in his right shoulder. Radiographs reveal continued delayed non-union at the
osteotomy site.
Recommendations: Observe for two months- may need surgery. Continue PT for right
shoulder llIjd do EMG for brachial plexus.
11/1/01 Pediatric Orthopedics
He needs an EMG for his right brachial plexus injury. He is receiving physical therapy for his
right shoulder. He is in a earn Walker with limited weightbearing left leg. X-rays suggest
interval healing. He is to continue PT and Cam Walker.
12/14101 Dr. Ramer- Developmental Pediatrician
He is attending a school program which is a combination of regular classroom and learning
support. He receives PT, OT, and Speech once per week and has an academic aide with him.
He gets fiustrated easily and has a problem with memory, especially short term memory. He is
able to dress and bathe himself. He can only walk short distances due to persistent non-union of
his left tibia. He is using a Cam walker. He continues to gain weight. He is complaining of low
back pain when he sits. He has significant pelvic tilt. He is in appropriate placement at school
and therapy. He has difficulty initiating voiding and requires an effort to void. He has problems
dribbling and soiling himself with urine after voiding. A urology evaluation with Dr. Dector is
appropriate. His weight is a concern and will impact negatively on his mobility and pulmonary
function.
12/27101 Pediatric Orthopedics
He went on to develop left tibial malunion post tibial osteotomy, despite compression plating.
Repeat x-rays revealed further evidence of widening at the osteotomy site with apparent
hypertrophic nonunion. He has been walking in a limited fashion with the cam walker. He has
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
Susquehanna ~ehabilitation -Services
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Rominger and Bayley Law Offices
Re: Matthew Brink
..... November 17, 2002
Page 7
surgery set for 3/26/02. He is to have his EMG for brachial plexus on 1/10/02. We have
tentatively recommended lliazarov external fixation with compression mode of his
hypertrophic nonunion and fibular osteotomies with plate removal. May want to consider take
down of the pseudoarthrosis and bone grafting at the time of the I1iazarov application which
will allow the patient to weight bear.
1/10/02 Report ofEMG
Interpretation: Abnormal study. The electrodiagnostic findings show chronic partial
denervation and re-innervation which is present in C5 innervated muscles and to a lesser degree
C6-7 innervated muscles. There is no evidence of active/ongoing denervation. This is
consistent with residual right brachial plexopathy affecting his upper trunk, which is now
relatively mild. There is nearly complete re-innervation of the muscles supplied by the middle
trunk.
2/25/02 Pediatric Orthopedics
He is being followed for a delayed union/non-union of the left tibia post tibial osteotomy, still
wearing hjs Cam walker. There is less than a 1 cm gap at the non-union site. He is to have
capacitance coupling and electrical stimulation to attempt healing without operative
intervention.
Plan: Return with x-rays in 10 weeks. He had an EMG for his right brachial plexus palsy
which showed further regeneration. He will continue OT for his right upper extremity.
2/28/02 Dr. Bonsall- Ophthalmology
He has a history of traumatic optic neuropathy and now has no light perception in his right eye.
He also has exotropia. The parents are not interested in eye muscle surgery at this time due to
upcoming leg surgery. He has a history of asthma and combative behavior.
Impression: Developmental delay secondary to brain injury. Exoptropia which is sensory.
Traumatic optic neuropathy. To be seen yearly.
5/9/02 Pediatric Orthopedics
He has been receiving electri~a1 stimulation capacitance coupling for a delayed union of his left
tibia. Radiographs reveal interval healing. The osteotomy line is clearly less distinct. He has
had the stimulator on 24/7 for 13 weeks. He has been bearing some weight on his left lower
extremity. EMG showed residual right brachial plexopathy but there is near complete re-
innervation of the middle trunk noted.
Recommendations: Continue with electrical stimulation for one month. Continue with Carn
Walker. May increase and progress to full weight bearing.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-3450 / Fax: 717-795-6204 / E-Mail: srs@srsrehab.com
. Susq'ueh~nna ~ehabilitat.ion Se~vices
www.srsrehab.comPA.MD · DC · OH · VA . WV · DE . NJ · NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 8
5/10/02 Initial PT Evaluation- Hershey Medical Center
Matthew underwent orthopedic surgery on 5/9/01 at which time he had right heel cord
lengthening as well as realignment of the lefLtibia. He currently has a Cam walker on his left
lower extremity. He only uses his wheelchair at school but is walking independently at home.
Recommendations: He should continue PT at school to continue focusing on strength,
coordination, and dynamic standing balance. He would benefit from increased physical therapy
in the summer. He may need an alignment assessment due to leg length discrepancies. He does
not need the wheelchair in school but should be supervised at all times when ambulating.
9/13/02 Dr. Ramer- Developmental Pediatrician
Follow up of severe brain injury. He continues to make slow improvement in walking. Sinemet
was not of benefit for his tremor and was stopped. He has continued to receive PT and OT with
slow improvement. The occupational therapist feels he has plateaued in arm use skills. Tremor
remains an issue. It is most evident when he is fatigued and tries to feed himself. It also
interferes with handwriting to a lesser degree. He continues to have excessive appetite and
weight gain. He is getting exercise by walking more. His learning skills are progressing slowly
and by the, end of school were thought to be plateauing. He can take care of most of his daily
care needs that are within his physical capability, but his learning of academics has been slow.
He is in learning support placement full time.
On examination his speech was slow and it was difficult to find words. His answers were
accurate, but superficial and brief. His right shoulder has markedly reduced strength. He had to
brace his elbow to use his right hand. Tremor is present on the left and related to weakness. His
gait and balance have improved. There were problems with foot position on the right and a
MAFO brace is pending.
Impression: Tremor related to weakness. To try a weighted arm bracelet to help with tremor.
This will also help strengthen the arm. He was given a prescription for PT and OR outside of
school. He will try Aricept initially at 2.5 mg per day and increase over one month to 5 mg/day.
This medication may help improve memory and reasoning skills.
Current Medical Status:
Matthew is followed at Hershey Medical Center by Dr. Ramer, developmental pediatrician and
physical medicine and rehabilitation specialist, Dr. Segal, orthopedic specialist, and
Dr. Bonsall, ophthalmology. A urology consultation has been recommended for continued
urinary hesitancy and incontinence. Matthew has had an increase in sinus infections which
Dr. Ramer relates to narrowed passages secondary to the facial trauma he sustained and is
followed by his primary care physician for this condition and for coordination of referrals.
Matthew receives outpatient physical and occupational therapy in addition to mandated
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-3450/ Fax: 717-795-6204/ E-Mail: srs@srsrehab.com
'Susq~eh~nna ~ehabilitation Se~ices
www.srsrehab.comPA.MD.DC.OH.VA · WV · DE . NJ · NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 9
services through the school. Matthew's left tibial fracture, despite osteotomy surgery and bone
stimulation, has healed with some degree of displacement and when he is at full bone growth,
will require repair with an external fixation device. He may also need bilateral heel cord
lengthening procedures in the future. Matthew has exotropia from the accident and may also
require eye muscle corrective surgery in the future for his right eye. Dr. Ramer has projected
that he may need tendon transfer surgery for his right brachial plexopathy. Matthew has visual
impairments and cognitive impairments and is a candidate for assistive technology such as low
vision aids and computer technology to increase his educational and vocational potential.
Matthew is currently on Aricept, a medication which is used to improve cognitive skills and
attention. He was on Sinemet for tremors but this was discontinued. He is on antibiotics at least
yearly for sinus infection. Matthew has a history of asthma and continues on inhaler
medication.
Chief Reuorted Problems IncIudiDl! Limitations and CauabiIities:
Matthew~as severe impairments as a result of his disabling conditions. He has visual
impairments on the right side. He has cognitive impairments including attention and
concentration problems, difficulty with short term memory, impulsivity, and emotional
outbursts. He has weakness on the right side as well as gait dysfunction requiring bracing for
both legs. He continues with little movement of his right shoulder and he must use his elbow to
brace himself so he can use his right hand. Matthew needs constant verbal cueing and
prompting to complete his morning tasks as motivation is difficult for him. He has difficulty
with lower extremity dressing and tying his shoes. Matthew has low back pain due to leg length
discrepancies which has resulted in a pelvic tilt. He has gained significant weight which puts
further stress on his musculoskeletal system. Due to excess weight, he often has fungal
infections in the folds of his skin. The tremor in his left arm has led to difficulty with self
feeding and in bums due to spilling hot water.
Records and consultation with Dr. Ramer, developmental pediatrician, indicate that Matthew
will likely not be able to live independently due to injuries sustained from this accident. This is
due his cognitive difficulties and high need at present for learning support. Dr. Ramer has
indicated that it is not likely that he will be competitively employed but may be able to work at
a sheltered workshop level of employment.
-
Environmental/Social:
Matthew is the youngest of several siblings and is the only child still living at home with his
parents. His father is permanently disabled from a stroke he sustained in 1995 and he is also
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-34501 Fax: 717-795-62041 E-Mail: srs@srsrehab.com
. Susq~ehanna ~ehabilitat.ion Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE . NJ · NY
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 10
legally blind. He had worked as an electrician and minister prior to his illness. Matthew's
mother works two jobs as a newspaper reporter and as records clerk for the Newville Police.
The family lives in a ranch home with a basement.
Educational:
Matthew is in full time learning support for academic subjects and is mainstreamed with the
regular classroom for specials such as art and music. Dr. Ramer has projected that he will need
special education throughout his school career. He will need assistive technology support for
computer use due to his visual and cognitive impairments which may include voice technology
and special software options.
Summarv:
Matthew Brink is a 10 year old boy who has sustained multiple injuries which include a severe
closed head injury, hypoxic ischemic encephalopathy, right adrenal hemorrhage, aspiration
pneumonitis, liver laceration, right orbital fracture, and right temporal bone fractures of the
face, a right brachial plexus injury, a right olecranon fracture, left tibial fracture, and injury to
the left lower ankle including avulsed skin flap and tendon injury. He has right sided
hemiparesis as well as visual impairments on the right side due to optic nerve injury. He has
deficits in motor, sensory, cognitive, physical, and socialization skills. Matthew will require
various medical treatments throughout his life as a result of these conditions. Matthew will
most likely require repair of the deformity of his left tibia as his bone reaches growth maturity
in the teen years. He may also require heel cord lengthening procedures, BoTox injections,
tendon transfer surgery for his right upper extremity, and eye muscle surgery in the future,
though the likelihood of these procedures is less certain. Matthew will continue to require
treatment for frequent sinus infections related to his facial injuries.
Dr. Ramer has projected that it is unlikely that Matthew will live independently and that this is
due to the severe traumatic brain injury that he sustained as a result of his 10/14/00 accident. It
is also unlikely that he will be competitively employed but he may be able to work at a
sheltered workshop level. He will require 24 hour care and supervision. Future care alternatives
in this Life Care Plan consist of care at home and assisted living as an alternative. The Brink
family would benefit at this time from respite care due to time consuming and exhausting
nature of Matthew's care needs. When Matthew is an adult, he would benefit from facilitator
services to ensure safety and compliance with his rehabilitation plan. As an alternative he can
live in an assisted living facility which would include opportunities for socialization and
vocational training. It is likely that Matthew will live at home as a younger adult, but may
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-34501 Fax: 717-795-62041 E-Mail: srs@srsrehab.com
Susqueh~nna ~ehabilitationSe~ices
~.~.oc.oo.~.wv.m.~.NY
www.srsrehab.com
Rominger and Bayley Law Offices
Re: Matthew Brink
November 17, 2002
Page 11
require an assisted living facility as his parents age and are no longer able to care for him.
There are also extremely limited sheltered workshop opportunities close to the client's home.
Dr. Ramer has recommended continued outpatient physical and occupational therapy as an
adjunct to mandated services. These will need to be increased in the summer. His weight gain is
a concern and access to a YMCA type facility for swim and gym opportunities would provide
maintenance level exercise opportunities. Neuropsychological evaluations are recommended
for an assessment of Matthew's cognitive status both now and through the school years. I
recommend availability of psychological counseling and/or cognitive therapy at each stage of
developmental crisis to assist adaptation to disability and patient/family coping strategies.
According to the National Center for Vital Statistic Life Table for White Males, 1999, Matthew
has 65 (65.3) years remaining. This Life Care Plan and associated costs have been based upon a
normal life expectancy.
The Appendices that follow outline the anticipated lifetime care and costs for Matthew Brink.
Throughoyt his life there will undoubtedly be some alterations to these projected costs. Please
note all costs reflect current market prices and do not include sales tax, shipping, or handling.
All growth trends need to be determined by an economist. All opinions have been stated with a
reasonable degree of professional certainty. I request the opportunity to amend my report if
new information should become available.
Prepared and submitted by,
Vet-lerie> V. Pcu-iW
Valerie V. Parisi, R.N., CRRN, CCM, CLCP
Certified Life Care Planner
Ivvp
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-34501 Fax: 717-795-62041 E-Mail: srs@srsrehab.com
Home Care Option
ITEM ANNUAL COST YEARS ONETIME/LIFETIME COSTS
Physical Therapy Evaluations $121.00 65 $7,865.00
Occupational Therapy Evaluations $121.00 65 $7,865.00
Neuropsychological Evaluations $4,200.00
Physical Therapy $7,744.00 11 $85,184.00
Occupational Therapy $7,744.00 11 $85,184.00
Case Management $180.00 65 $11,700.00
Behavioral Counseling $3,600.00
YMCA $450.00 65 $29,325.00
HOIlle Care Before Age 21 $33,150.00 11 $364,650.00
Home Care After Age 21 $102,600.00 54 $5,540,400.00
Medications $1,693.96 65 $110,107.40
Physical Medicine until age 16 $360.00 6 $2,160.00
Physical Medicine $180.00 59 $10,620.00
Orthopedics until age 16 $640.00 6 $3,840.00
Orthopedics $160.00 59 $9,440.00
Ophthalmologist $60.00 65 $3,900.00
Urologist $60.00 65 $3,900.00
Primary Care $112.00 65 $7,280.00
X-rays until age 16 $444.00 6 $2,664.00
X-rays $111.00 59 $6,549.00
EMG $688.00
Urodynamic Testing $2,000.00
Scooter $873.33 54 $47,159.82
Quad Cane $5.00 65 $325.00
Shower Chair $24.00 65 $1,560.00
Hand Held Shower $9.00 65 $585.00
Grab bars and shower mat $20.00 65 $1,300.00
Safety Aids! A~ptive Aids $50.00 65 $3,250.00
Raised Toilet Seat $20.00 65 $1,300.00
Bilateral AFO's until age 21 $2,086.00 11 $22,946.00
Bilateral AFO's $1,043.00 59 $61,537.00
Orthotic insole for shoe $65.00 65 $4,225.00
Software $250.00 65 $16,250.00
Transportation $164.41 59 $9,700.19
$0.00
$6,473,259.41
Residential Option
ITEM
Physical Therapy Evaluations
Occupational Therapy Evaluations
Neuropsychological Evaluations
Physical Therapy
Occupational Therapy
Case Management
Behavioral Counseling
YMCA
Home Care Before Age 21
Community Residential Services
Medications
Physical Medicine until age 16
Physical Medicine
Orthopedics until age 16
Orthopedics
Ophthalmologist
Urologist
Primary Care
X-rays until age 16
X-rays
EMG
Urodynamic Testing
Scooter
Bilateral AFO's until age 21
Bilateral AFO's
Orthotic insole for shoe
Software
ANNUAL COST
$121.00
$121.00
$7,744.00
$7,744.00
$180.00
$450.00
$33,150.00
$100,192.50
$1,693.96
$360.00
$180.00
$640.00
$160.00
$60.00
$60.00
$112.00
$444.00
$111.00
$873.33
$2,086.00
$1,043.00
$65.00
$250.00
YEARS
65
65
11
11
65
65
11
54
65
6
59
6
59
65
65
65
6
59
54
11
59
65
65
ONETIME/LIFETIME COSTS
. .'. __u_...
$7,865.00
$7,865.00
$4,200.00
$85,184.00
$85,184.00
$11,700.00
$3,600.00
$29,325.00
$364,650.00
$5,410,395.00
$110,107.40
$2,160.00
$10,620.00
$3,840.00
$9,440.00
$3,900.00
$3,900.00
$7,280.00
$2,664.00
$6,549.00
$688.00
$2,000.00
$47,159.82
$22,946.00
$61,537.00
$4,225.00
$16,250.00
$6,325,234.22
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SUSQUEHANNA REHABILITATIO~ SERVICES
PO BOX 335
MECHANICSBURG, PA 17050
,
-..,..
v
JJ,!J,!O)/
Federal Tax 10 #: 23-257-4977
INVOICE for
Professional Services
KARL ROMINGER, ESQUIRE
ROMINGER & BAYLEY LAW OFFICES
155 SOUTH HANOVER STREET
CARISLE, PA 17013
===============================================================================
Our Case Code : 2002-111
Client Name : BRINK, MATTHEW
Insured : N/A
Your Reference: N/A
-
Invoice No.: 979000102
Invc. Date: 11/17/02
Page Number: 1
Injury Date: 10/14/00
===============================================================================
Date
Description of Service Performed
Prof TrlWt Mlg
Other
-------------------------------------------------------------------------------
09/13/02 COpy OF MEDICALS @ $25/HOUR 0.50 0.00 0 50.30
09/16/02 RETAINER FEE/CHECK #1498 -1000.00
09/20/02 REVIEW MEDICAL RECORDS 4.00 0.00 0 0.00
09/26/02 VISIT CLIENT 2.00 0.00 0 0.00
09/26/02 TRAVEL 0.00 6.00 320 0.00
09/30/02 PCIPHYSICIAN 0.20 0.00 0 0.00
09/30/02 REVIEW MEDICAL RECORDS 0.50 0.00 0 0.00
11/01102 PC/THERAPIST 0.20 0.00 0 3.96
11/01/02 PCIOTHER AGENCY/PROFESSIONAL 0.30 0.00 -0 -- 5.94
11/01102 PC/OTHER AGENCY/PROFESSIONAL 0.30 0.00 0 5.94
11/01/02 PC/PHYSICIAN 0.30 0.00 0 5.94
11/01/02 PCIOTHER AGENCY/PROFESSIONAL 0.30 0.00 0 5.94
11/10/02 RBSEARCH VIA INTERNET 1. 70 0.00 O. 0.00
11/17/02 RBPORT AND APPENDIX(S) 7.00 0.00 0 10.00
-------------------------------------------------------------------------------
-
TOTALS
17.30
6.00 320 -911.98
-
-
Professional Hours ($125.00/Hr)
TravellWait Hours ($125.00/Hr)..
Mileage (0.390/Mile) .
Other fees . . . . . . .
GRAND TOTAL THIS INVOICE . . . .
2112.50
750.00
124.80
-911. 98
2075.32
-
-
-
-------------------------------------------------------------------------------
Susquehanna ~ehabilitation 'Services
www.srsrehab.comPA.MD.DC.OH.VA . wv · DE . NJ · NY
Attention:
SRS Number:
Date of Referral:
Rominger and Bayley
Law Offices
155 South Hanover Street
Carlisle PA 17013
Karl Rominger
2002-111
9/11/02
To Account:
Date:
Plaintiff:
D.O.A.:
D.O.B.:
Disability:
March 10, 2003
Matthew Brink
10/14/00
12/31191
Severe Traumatic Brain Injury
Right Hemiparesis
Multiple Orthopedic Trauma
Vocational Assessment
Introduction:
Susquehanna Rehabilitation Services has been requested to determine the loss of earning
capacity ofMr. Matthew Brink as a result of his accident on October 14, 2000. Matthew is an
I I year-old white male, who on October 14, 2000, was struck by an automobile while he was
riding his bicycle. Matthew sustained multiple traumatic injuries including a closed head
injury, hypoxic ischemic encephalopathy, right adrenal hemorrhage, aspiration pneumonitis,
liver laceration, right orbital fracture, right temporal bone fractures of the face, a right brachial
plexus injury, a right olecranon fracture, left tibial fracture, and an injury to the left lower ankle
including avulsed skin flap and tendon injury. Matthew has suffered right-sided hemiparesis as
well as loss of vision in the right eye due to an optic nerve injury. As a result of Matthew's
injuries and permanent physical limitations, he will experience a loss in future wages and fringe
benefits in the amount of$I,005,033.
This report will reflect Matthew's educational history and earnings loss as a result of the
automobile accident of October 14, 2000. In addition to my meeting with Matthew and his
parents, I have also been provided with the following documents in preparation of this report:
I. Matthew's school records from Shippensburg Area School District.
2. Life Care Plan dated November 17, 2002, by Valarie V. Parisi, RN, CRRN, LNC, CLCP
3. Records of Stephen Becker, M.D. from January 15,2001 to March 11,2002.
4. Records from Milton S. Hershey Medical Center dated October 14, 2000 to September 13,
2002.
5. Police report from the Pennsylvania State Police dated October 14, 2000.
6. May 10, 2002 report from Jessica Greenlee, M.S., P.T.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 I Mechanicsburg, PA 17050
Telephone: 800-836-3450 1 Fax: 717-795-6204 1 E-Mail: srs@srsrehab.com
&h, hi t 118"
Susquehanna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE . NJ . NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 2
Medical Status:
Matthew's medical treatment has been summarized in the life care plan written by
Valerie Parisi, R.N., CRRN, LNC, CLCP, and will not be repeated here. I had the opportunity
to meet with Matthew and his parents on February 6, 2003. At that time, Matthew was
occasionally experiencing severe tremors with his left arm. He had also suffered a right
brachial plexus injury. Matthew had limited movement with overhead reaching. Due to optic
nerve damage, he is unable to see out of his right eye. Matthew wears a right ankle brace and a
left foot-drop brace. Prior to this accident, his parents stated that he had no physical
complaints. However, the records reflect that Matthew did receive occupational therapy at
school to help with his writing and hand movements. The only prescription medication that is
taken is Aricept to increase brain function.
Educational Ristorv:
Matthew started his formal education in the Big Spring School District.. He attended the Head
Start program and on October 16, 1996, was tested by Alexander Spring Rehab, Inc. The
testing showed that Matthew's verbal and language skills were approximately one year below
his age at that time, 4 years and 9 months. It was recommended that Matthew receive speech
therapy one time per week through the head start program. Matthew was successful in reaching
his verbal goals through this program, but not the written goals. He was discharged on March
27, 1997. At that time it was recommended that he receive a complete speech and language
screening upon admission to Kindergarten.
An occupational therapy evaluation was completed on April 21, 1998. This was through the
Capital Area Intermediate Unit. There was a concern about Matthew's fine motor skills. The
Bruinisks-Oseretsky Test of Motor Proficiency and the Developmental Test of Visual-Motor
Integration were administered. Matthew was found to have normal postural tone. He was able
to run and gallop, but could not perform higher-level skills such as skipping and jumping jacks.
He held his pencil in a hooked wrist position and had difficulty with letter formation. As a
result of the testing, Matthew received in school occupational therapy.
On March 17, 1999, a comprehensive evaluation report (CER) was completed by the Big
Spring School District. Matthew had been administered the Kaufman Brief Intelligence Test.
This showed his cognitive functioning to be within the average range with a vocabulary score
of 94, matrices score of 93 and full scale score of 93. This testing apparently had been
administered in January 1998 when Matthew was in Kindergarten. The Wechsler Intelligence
Scale for Children-Third Edition was administered for the CER. His verbal I.Q. was 80 and
performance I.Q. 74. Matthew's full scale I.Q. was 75, which is mildly mentally retarded.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 3351 Mechanicsburg, PA 17050
Telephone: 800-836-3450 1 Fax: 717-795-62041 E-Mail: srs@srsrehab.com
Susquehanna ~ehabilitation 'Services
www.srsrehab.comPA.MD.DC.OH.VA · wv · DE . NJ · NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 3
Matthew was found to have very poor math skills. He also took the Wechsler Individual
Achievement Test. This showed a listening comprehension score of 108, which was better than
expected. His reading, spelling and math abilities were below average. Matthew's parents
agreed with the Individualized Education Program (IEP), but disagreed with the cognitive
testing.
In September, 2000, Matthew started the third grade. According'to his father, Matthew was
held back for the first grade. This does not appear to be documented in any of the records that I
have reviewed. The IEP for the school year 1999-2000 was completed when Matthew was 8
years, 3 months old. He was in grade 2-8, which would be age appropriate.
The Woodcock-Johnson Achievement Test was administered on April 25. 2000. The grade
level results from this testing is as follows:
LetterlWord Identification: K.9
Passage Comprehension: 1.3
Dictation:' I. 5
Math Calculation:
Applied Problems:
Quantitative Concepts:
1.9
1.4
1.5
Matthew's math, speech and language skills were all improved. It was recommended that since
Matthew was functioning one year below his grade level that he received modifications in his
educational program through the learning support resource classroom. It was also
recommended that he receive the services of an occupational therapist I -2 times per month to
assist him with his handwriting.
The Woodcock-Johnson Achievement Test was administered again on August 29, 2000. The
grade level results from this testing is as follows:
LetterlWord Identification:
Passage Comprehension:
Dictation:
Reading Instructional Level:
Grade Equivalent
K.8
1.4
1.5
PP-2
It does not appear that the other portions of this test were administered. According to the
records from Shippensburg Area School District, Matthew continued to make progress, but
remained significantly behind his peers. He was starting third grade at this time and had been
in learning support for language arts and math. He also received assistance with other class
work and studying for tests.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450 1 Fax: 717-795-62041 E-Mail: srs@srsrehab.com
Susquehanna ~ehabilitation 'Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE · NJ . NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 4
Matthew was involved in his accident on October 14, 2000. This disrupted his schooling and
accommodations were made with the school district to provide him with instruction outside of
the classroom.
At the beginning of the fourth grade, Matthew had another IEP completed, September, 2001.
The report outlines that Matthew had been receiving occupational therapy I -2 times per week.
He was experiencing tremors with his left upper extremity and used his left hand to raise his
right arm. He was having difficulty with fine manual dexterity with his right hand. Matthew
was wheelchair bound and continued to have difficulty with concentration. Occupational
therapy and physical therapy were both recommended once per week. He was able to use age
appropriate speech and language, but had difficulty with saying more than 4 or 5 words at a
time. The Woodcock-Johnson Achievement Test was again administered on August 28, 2001.
The results are as follows:
LetterlWord Identification:
Passage Comprehension:
Calculation:
Applied Math:
Grade Equivalent
K.7
(No Basal)
1.4
K.O
Matthew was able to count by five's and ten's at a 50% accuracy rate. He was able to identifY
basic coins by name and value about 50% of the time. This testing is significantly lower than
the testing completed prior to Matthew's accident. His math ability had not been tested in 18
months and one would expect improvement since the last formal testing. In April, 2000,
Matthew scored at almost the second grade. During the testing following the accident, he
scored at entry-level kindergarten. His passage comprehension score dropped to the grade 1.4
to not being able to be tested. Prior to the accident, Matthew had received specialized
instruction and had participated in some of the general education curriculum. The IEP
indicates that he is no longer cognitively able to do so.
Another IEP was completed on May 16, 2002. The Woodcock-Johnson Tests of Achievement
were again administered. The results were as follows:
Letter-Word Identification:
Passage Comprehension:
Dictation:
Calculation:
Applied Problems:
Grade Equivalent
1.0
<1.0
1.5
1.9
l.l
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 1 Mechanicsburg, PA 17050
Telephone: 800-836-34501 Fax: 717-795-62041 E-Mail: srs@srsrehab.com
Susquehanna ~ehabilitation Services
www.srsrehab.comPA.MD.DC.OH.VA.WV.DE · NJ · NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 5
The test of word reading efficiency was also administered. The results of the sight word
efficiency and phonetic decoding efficiency places Matthew below the I" percentile. It was
recommended that Matthew receive speechlIanguage therapy 30 minutes per week and
occupational therapy 30 minutes per week. Previously, Matthew had made enough progress
that it was not recommended that he be in the extended school year program. Unfortunately,
due to his regression and traumatic brain injury, the extended school year was found to be
necessary. His time of receiving special education outside of the regular education classroom
was increased to 6 I % or more.
The last IEP evaluation in the materials is dated November 4, 2002. At that time, Matthew was
receiving direct instruction in reading, written language, math and content subjects from the
learning support program. He was receiving speech and language support once a week. He
was also receiving occupational therapy and physical therapy once a week. In addition,
Matthew was receiving adaptive physical education. Due to the loss of vision in Matthew's
right eye, he had been receiving support services through the Capital Area Intermediate Unit.
This included adaptations in his placement in the classroom and size of print that he was given
to read. Matthew also had qualified for adaptive technology for use on the computer.
The principal of Matthew's school, Susan M. Martin, has sent correspondence to
Jeanette Ramer, M.D. regarding his progress in school. Most of the comments are behavioral
in nature instead of academic.
At the time of my meeting with Matthew he was eleven years old and in the 5th grade at Nancy
Grayson Elementary School in the Shippensburg Area School District. He was in learning
support for all classes, except for art and music. He was receiving speech therapy once a week
at school. He also was receiving occupational therapy and physical therapy once a week at
school. Matthew showed me his report card for the second marking period. He received C's in
reading, writing, spelling, and math. He received S's in art, vocal music, physical education
and library. It is important to keep in mind that these grades are not representative of
Matthew's performance based on the typical grading system. These are learning support
grades, as Matthew would not be able to pass these subjects in a regular classroom. In fact,
Matthew has not been able to make progress in the learning support environment and will enter
the life skills program next year. This will focus on teaching him how to cook, make change
and take care of himself. This program continues through the 12th grade. This program will
focus on job skills and provides a job coach in an attempt to assist the student in obtaining
some type of employment.
During my meeting with Matthew, I administered two tests. The Wide Range Achievement
Test, Revision 3, tan version and the Slosson Intelligence Test. Matthew was unable to spell
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 1 Mechanicsburg, PA 17050
Telephone: 800-836-3450 I Fax: 717-795-62041 E-Mail: srs@srsrehab.com
Susquehanna ~ehabilitation Services
www.srsrehab.com
~.~.oc.oo.~.wv.m.~.NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 6
his last name, he was unable to write the letter g or d. He wrote e, instead of g and was unable
to write any letter when asked to for the letter d. He was also unable to spell four out of the
first five words of the test. Matthew was able to spell cat, but not: go, boy, run or will. He
needed to use his fingers to perform basic arithmetic. He was unable to subtract 1 from 3, 3
from 9 or add 3 plus 4. Matthew was unable to read the letters u, v, andj. He pronounced the
word "was" as "saw". The results of this testing shows that Matthew is functioning at the
kindergarten level in reading, spelling and arithmetic. He is at the .02 percentile in reading and
arithmetic. He is at the .5 percentile in spelling. This means that 99.92 out of 100 children of
Matthew's age are able to function at a higher level than he is in reading and arithmetic. 99.5
out of 100 are able to function higher in spelling.
The results of the Slosson Intelligence Test shows that Matthew is currently functioning with a
Total Standard Score at the 95% confidence interval of between 39 and 53. This represents an
I.Q. of 53 on the Wechsler scale, someone who is moderately mentally handicapped.
The optimum determination of future earning capacity is to assess future educational
attainment. Weed (2000) eXplained that when one is trying to determine the earnings potential
of children, the vocational expert should consider the types of jobs that the parents or siblings
have held, and the child's potential educational attainment. Weed outlines that the child is
likely to gain a little more education than their parents, unless the parents are at the extremes of
the level of educational attainment, in that case, children seem to regress towards the mean.
Matthew's father, Tom Brink, graduated from high school in 1967 and took Ministry courses.
He was a Minister for 22 years. He also was a Journeyman Electrician. He has diabetes
mellitus, is legally blind. He also has had a stroke and several heart attacks. Mr. Brink has been
on disability since June 1995. Matthew's mother, Lisa Brink, graduated from high school in
1969 and has taken additional computer courses. She has worked for the newspaper in
Shippensburg as an Assistant Circulation Manager and Advertising Clerk. For the past four
years, Mrs. Brink has worked part-time as a Reporter and Photographer for the newspaper. She
also works 25 hours per week as a Clerk for the Newville Police Department. She is a
Community Service Officer, collecting money from parking meters, writing parking tickets,
completing data entry, filing and making telephone calls. At the time of Matthew's accident,
Mrs. Brink was employed as an Advertising Clerk for the newspaper working 20-25 hours per
week and making $6.50 per hour. She was unable to work from October 2000 to April 2001 as
she was taking care of Matthew.
Matthew has one brother and two sisters who have graduated from high school. Two sisters
did not complete their educations. One sister completed the 8th grade and another completed
the 9th grade. He has one brother who is still in school.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 3351 Mechanicsburg, PA 17050
Telephone: 800-836-34501 Fax: 717-795-62041 E-Mail: srs@srsrehab.com
Susquehanna ~ehabilitation 'Services
www.srsrehab.com
~.~.oc.oo.~.wv.m.~.NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 7
Conclusions:
Matthew Brink was in learning support classes prior to the accident of October 14, 2000. He
was functioning at one grade level below his peers, but making progress. In 1998, the
Kaufman Brief, Mental Ability Test was administered which resulted in a verbal score of 94
and math score of 93. The composite score was 93. The report of Mark Haas, school
psychologist with Shippensburg Area School District indicates that a WISC-Ill test was
completed when Matthew was at the Big Spring School District, which gave him a full-scale
I.Q of 75. This would have placed Matthew's level of functioning in the mildly mentally
retarded range. There is no reference that this testing was repeated. This testing would have
taken place when Matthew was in the first grade at the latest.
Based on Matthew's home environment and the studies that have been published, it is possible
that he would have graduated from high school. However, based on his level of functioning
prior to the accident, I find it unlikely that he would have had the cognitive ability of the typical
high school graduate. Therefore, Matthew's future educational attainment pre-injury, is best
represented by someone who is not a high school graduate. Following the accident, all of the
testing areas have shown a significant reduction in Matthew's academic abilities. Even though
he is eleven years of age and in the fifth grade, he is functioning at the kindergarten level in all
academic areas. He is unable to write his last name or spell the most basic of words. The result
of the traumatic brain injury that Matthew suffered has reduced his I.Q. to 53, placing Matthew
in the moderately mentally handicapped range. In addition to these deficits, Matthew has lost
the vision in his right eye, has tremors in his left arm and limited range of motion of his right
arm. He also wears braces on both legs. The combination of these factors renders him disabled
from performing gainful employment. As these conditions are permanent, it is not anticipated
that Matthew's status will change.
The mean earnings ofa male, 16 to 24 years of age, without a high school diploma is $18,962.1
At the time of the accident, Matthew was 9.79 years of age. He would have a WorkIife
expectancy, following his 18th birthday of 33.33 years2 As a result of Kaczkowski v.
BoJubasz, future earnings are not to be reduced to present valueJ However, they can be
adjusted for increases attributed to productivity. The increase in earnings due to productivity
) Disability, Work Experience and Mean Earnings in2000-Work Disability Status of Civilians 16 to 74 Years
Old, by Edncational Attainment and Sex: 2002.. U.S. Census Bureau.
2 Worklife Estimates: Effects of Race and Education. U.S. Depanment of Labor, Bureau of Labor Statistics,
February. 1986 Bulletin 2254., for all men with less than high school education.
3421 A.2d 1027, 491 Pa. 561 Kaczkowski v. Bolubasz. (Pa. 1980)
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 335 / Mechanicsburg, PA 17050
Telephone: 800-836-3450 I Fax: 717-795-62041 E-Mail: srs@srsrehab.com
, .
Susquehanna ~ehabilitation -Services
www.srsrehab.comPA.MD . DC . OH · VA · WV · DE . NJ . NY
Vocational Assessment
Re: Matthew Brink
March 10, 2003
Page 8
equals 1.3%.4 Matthew would also have the opportunity to earn fringe benefits while being
employed. These would equal 18.3% of his earnings.s
Proiected Dre-iniurv earninl!s o(Matthew Brink (rom al!t 18 to WorkIi(e exuectancv
From I!!.
-12/31109 02112/43
OccuDation
Laborer
Totals:
Annual
Earninl!s
$18.962
$849,566
Fringe
Benefits
$3.470
$155,467
Growth
Rate
1.3%
Matthew Brink's pre-injury earnings and fringe benefits, from age 18 to his Worklife
expectancy, age 52.12, equals: $1,005,033.
From a vocational perspective, his combination of reduced I.Q., loss of vision in his right eye
and multiple other physical impairments will preclude Matthew from sustaining competitive
gainful employment in the future. There is no offset to the amount that Matthew is projected to
have made over his lifetime.
The opinions contained in this report are within a reasonable degree of vocational certainty
based on the data that has been provided.
Sincerely,
Terry P. L~
Terry P. Leslie, M.Ed, CRC, ABVE, LPC
Vocational Counselor
Itpl
-
· 2002 OASDI Trustees Repon. U.S. Social Security Administration.
S Fringe Benefits infonnatiou from "The 200 I Employee Benefits Study", U.S. Chamber of Commerce, Statistics
and Research Center.
Sensitive To Your Rehabilitation Needs
Home Office: P.O. Box 3351 Mechanicsburg, PA 17050
Telephone: 800-836-34501 Fax: 717-795-62041 E-Mail: srs@srsrehab.com
"''''"
'i< "
"..
HarleysvIlle.
Good people to know
March 15,2002
Karl E. Rominger
Rominger Law Offices
155 South Hanover Street
Carlisle PA 17013
RE: Your client:
Our Insured
Claim #
Date/loss
Dear Mr. Rominger:
MidAtlantic Claims Service Center
Office Address Mailing Address
308 Harper Drive, Suite 200 P.O. Box 1016
Moorestown, NJ Moorestown, NJ
08057-3245 08057-0916
(888) 595-9876 Fax (856) 642-1699
www.harlevsvilleqroup.com
",--.- -",
"'''.-.,-.-.
j,.>,
;-~=-""~r.~'
,[;\' :11'4
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Matthew Brink, a minor
Lisa & Thomas Brink
MO 121711 WD
10/14/00
Be advised we do not wish to pursue subrogation in the above matter. Also, I am
enclosing as per your request, a certified copy of the policy relative to the above matter.
Should you need anything further, please advise.
sincrfly'n
ttitl..-\jl-~
Ann Pilla
Sr. Claims Specialist
1 888 595 9876 x 2346
Exn',bi-l "Co"
RECEIPT REU":ASE ANn tRUST AGREEMENT
rOR AND IN CONSIDERA nON of the payment to melus, Lisa Brink and Thomas Brink, on behalf of Matthew Brink, a minor
of the sum of Sixty Thousand dollars ($60,000.00) by the HarleysvillelPennland Insurance Companies, the receipt of which is
hereby acknowledged, I/we do hereby fully release and forever discharge said Companies from any and all claims and causes of
action, which I/we now have or may have against said Company under the Uninsured Motorist I Under Insured Motorist provision
of Policy, No PAA 356429 resulting from an accident which occurred on the 14 day of October 2000 at Newburg PA.
I/we further agree in consideration of this settlement and payment pursuant thereto to perform and comply fully with all the terms
and conditions of the aforementioned policy, indicating the trust agreement contained therein and incorporated in their release,
which is stated in the policy as follows:
Trust Agreement. In the event of payment to any person under this policy.
(a) the company shall be entitled to the extent of such payment to the proceeds of any settlement or judgment that may result
from the exercise of any rights of recovery of such person against any person or organization legally responsible for the
bodily injury andlor property damage;
(b) such person shall hold in trust for the benefit of the Company all rights of recovery which he shall have against such other
person or organization because of the damages which are the subject of claim made under this policy;
(c) such person shall do whatever is proper to secure and shall do nothing after loss to prejudice such rights;
(d) if requested in writing by the Company, such person shall take, through any representative designated by the Company,
such action as may be necessary or appropriate to recover such payment as damages from such other person or
organization, such action to be taken in the name of such person; in the event of a recovery" the Company shall be
reimbursed out of such recovery for expenses costs and attorney's fees incurred by it in connection therewith;
(e) such person shall execute and deliver to the Company such instruments and papers as may be appropriate to secure the
rights and obligations of such person and the Company established by this provision.
I/we further state that I/we have carefully read the foregoing release and trust agreement and know the contents hereof, and I/we
signed the same as my{our own free act.
WITNESS mylour hand and seal this
?vcl
day of _- /1 r tr; / , z OC ..s
CAUTION READ BEFORE SIGNING
~\ -'. [' .. !)
~JJ1 ( n;. ",j).) ,.,^-l~'\ }
'-f' y '"-).~ ...J 1'1., .,>,-1'
(Seal)
Signed in the presence of
I~f t /(~. 'l,.-, (; ~> t~_
/'
"
'-~.::- .r./~
-. '. .
)
}
}
}
}
)
)
}
}
}
}
}
(Seal)
State of
County of
On this _ J rd day of ;:1/'1' , .- .;Y:-7 before me personally appeared
"
,l/5,tJ / 7 C~} ,,-r'/!' - andIY;,:! i)) ,r! oS i)> ,/' e to know to be the
person described herein, and who executed the foregoing instrument and who acknowledged that voluntarily executed the same.
\." . . ')
My term expires - t~ ~-f -li/I.. .:;(.,/. _,?-1 L'&,:-..J. (,JU /:)':',"~~':':'- t ,,--:..__
, , . /
1 Notarial Soa!Nmary I-ubl'1
UI1da J. Jllmper, Notary PuIJ!-c
Carlisle BolO, Cumbelland County
My CommIssioo E>q:ires July 23. 2006
(C-498 12/98) (If this release is acknowledged before a ~~~ll~ are neces.<ary)
Claim # MO 121711 WD
E)(hibit "D"
.
Berkshire Mutual Insurance Company
Great Oaks Insurance Company
Harleysville.Atlantic Insurance Company
Harleysville-Garden State Insurance Company
Harleysville Insurance Company of New Jersey
Harleysville Mutual Insurance Company
Huron Insurance Company
Mainland Insurance Company
Mid-America Insurance Company
Penn land Insurance Company
Worcester Insurance Company
LETTER OF CERTIFICATION
Ann Pilla
Mid-Atlantic Claims Service Center
This is to certify that the attached is a true and correct copy of:
Personal Auto #PAA-356429, all policy terms from 06/04/00 to 06/04/01,
January 24, 2002
insofar as it relates to the insurance afforded thereunder at the following location:
275 Newburg Rd. Newburg, P A 17240, to the Named Insured: Lisa A Brink,
on the date of the loss 10/14/00, and purchased in Pennsylvania.
~:~h, bit \If.. It
~~
Susan Erney-Skelton
Assistant Vice- President
PAGE G3 ISSUE 11/01/00
G'
leoal
,--
i PAA 3S 64 29
AMENDED
PEASOHAL AUTO POLICY DECLARATIOHS
PEHHLAHD IHSURAHCE CDHPAHV
HARLEVSVILLE PA 19~3a
P.. 35 6~ 29
DIRECT BILL
LISA A BRIH.
27S HEWBURG RD
HEHBURO PA 172~0
BEL"DHT BRA"DT . .HOLL IHC T/A
DAHA BRAHDT IHSURAHCE
27 I IECDHD IT
HEHPDRT PA 1707~
10-11-00 71-75~2
AGEHT TELEPHDHE:717-567-6060
06-0~-00 TD 06-0~-01
OAIGIHAL POLICY DATE 06/99
PREFERRED
YOUR POLICV HAS BEEH CHAHOED IH THE FDLLOHIHG HAHHER
CHAHGE IH POLICV IHFORHATIDH
................. BASIC COVERAGES .................
THE COVERAGES BELOW ARE PROVIDED FOR VEHICLES WHERE A PREMIUM IS CHARGED
OR THE WORD IHClUOED IS DISPLAVED.
PRE"IU"9 FOR YEHICLE .
---11--- ---12--- ---13--- .--14---
LI"ITED TORT OPTIOH SELECTED.
HO EXTRAORDIHARY "EalCAL EXPEHSE IEHEFITS COYERAGE SELECTED
--------LIHITS-------- 19 PLVH II CHEY 17 CHRV 6~ PLY"
-COYERAOE-
SODILV IHJURY , 25.100 ERCH PERSOH
, 50.000 EACH ACCIDEHT' 73.00' 73.00' 120.00 , 301.00
PRDPERTV DAHAOE , 25.000 EACH ACCIDEHT' 50.00' 50.00' B2.00' 212.00
UHIHSURED HOTORIST
UHSTRC.ED , 15.010 ERCH PERSOH
, 30.000 EACH ACCIDEHT' 19.00' I~.OO' I~.OO' I~.OO
UHDERIHSURED HOTORIST
UHSTRC.ED , 15.000 ERCH PERSOH
, 30.000 EACH ACCIOEHT' 13.00' 10.00' 10.10' 10.01
FIRST PARTV BEHEFIT6-EACH PERSDH -PP0551' 2~.10' 2~.00' 2B.IO' 103.00
HEDICAL EXPEHSES '5,000 IHCLUDED IHCLUDED IHCLUDED IHCLUDED
HOR. LOSS HOHE
ACCIDEHTAL DEATH HDHE
FUHERAL HDHE
-COVERAGE FORDA"AGE TO YOUR AUTO
OTHER THAH COLLISIOH , 500 DEDUCTIBLE 'I~.O'
TOHIHO , SO EACH DIIABLE"EHT' 5.01
COLLISIOH , 500 OEOUCTlBLE '13.01
REHTAL REIHBURSEHEHT 'IS PER DRV/'~50 TDTAL IHCLUDEO
REYISED PER YEHICLE TOTAL , 261.10 , 171.01 , 2~.11 . 6~7.11
VEHICLE PREHIU" AOJUSTIlEHT FOR CHARGE . 59.01
...................................................
REYIIED TDTAL POLICY PRE"IUM . 1333.0'
POLICY PRE"IUIl ADJUlTIlEIlT FOR CHARGE. 5t.0I
...............................~~..................
PADE II ISM 11111101 G4 I
u. ;'
PREY FICHE 10 02B5-007H09
PRIOR TER" ID
LAST TRAHS: CHAHOE OH POLICV
DATE RECD 10/31/00 EHTRY DATE 11/01/'0
CURREHT-ACTIYE <REHEHALl
CYCLE 11/01/00
PRIOR ITATU' 01
~
IHTERFACEO
LAST CHO OT 10/11/00 LAST PRE" CHG DT IG/11/00
SDIP DT 06l9t
PREF EHTER:060~00
TIER-QUALIFY F, TIER-EHTEA FF
OYERIDES:
SUB CLASS PREP DATE 04/14/00
DHHED
-RATE ISSUE DATES-- ... STAT IHFO ....
YEHI YEH2 YEH3 YEH~ SUBL PER ACC STEXC
9IOB 9101 9101 9111 501 OS 10 5
9101 9IIB 9111 9101 502 OS
9111 9IOB 9108 9101 50S 03 06 6
9101 9101 9101 9101 520 06 5
saOl
saOl
saOl
530
531
530
722
077
70<
PER POLJ8T 37,T[AR 027CA"CELlATIOH FACTOR:
, FED-E"P
.7'
~ ~oL~Q _
PAA 35 6~ 29
06-0~-00 TO 06-0~-01
10-11-00
.................... MESSAGES .....................
VOUR POLICV HAS SEEH DISCOUHTED 151 TO REFLECT VOUR DRIVIHG RECORD
WARHIHG HOTICE. AMY PERSOH MHO KHDMIHGLY AHD MITH IKTEKT TO DEFRAUD AMY
IHSURAHCE CDHPAMY DR OTHER PERSDH FILES AH APPLICATIDH FOR IHSURAHCE DR
STATEHEHT OF CLAIH COHTAIHIHG AMY HATERIALLY FALSE IHFORMATION OR COHCEALS FOR
THE PURPOSE OF HISLEAOIHG. IHFORHATIOH COHCERHIHG AMY FACT AATERIAL THERETO
COHHITS A FRAUDULEHT IHSURAHCE ACT. MHICH IS A CRIAE AHD SUBJECTS THE PERSOH
TO CRIHIHAL AHD CIVIL PENALTIES.
.............. VEHICLE DE8CRIPTIONS ...............
VEHICLE
I VR OESCRIPTIOH VEH 10 HUHSER TERR CLASS DR X DR X DR X DR X
1 S9 PLVH MAG ~X2 IP~FH5~3IKX639060 PA-027 11112H 1-100
SVH 01 FACTORS .70
2 II CHEVRPU IGCCCI~05SSIIS~II PA-027 11112H 1-100
SYH II FACTORS .70
3 17 CHRY COUPE 20 3C3CJ~IK5HT73~~13 PA-027 aa~L2H 3-100
SVH 10 ,FACTORS 1.15
~ 6~ PLVHOSDH 3246136B46KKXKXXX PA-027 171D2H 2-100
SVH 07 FACTORS 2.95
... ADDITIONAL VEHICLE INfORMATION AHD DISCOUNTS ..
...THE FOllDWI"G INfOR"ATIOH APPLIES TO IHDICATED VEHICLE HUHIERS.
II DRIVEH, FOR PLEASURE DR LESS THAH 3 HILES TO MORK 00012 AHHUAL HILES
HULTI-CAR OISCOUKT -251
12 ORIVEH: FOR PLEASURE DR LESS THAH 3 HILES TO MORK 00012 AHHUAL HILES
HULTI-CAR OISCOUKT -251
13 ORIVEH: FOR PLEASURE OR LE6S THAH 3 HILES TO MORK 12000 AHHUAL HILES
HULTI-CAR OISCOUKT -251
PASSIVE REITRAlKT DISCOUHT -30X OH FIRST PARTY SEHEFITS
HOH-HOTORIIZED RESTRAlKT COVERAOE
.4 DRIVENl fQR P~EASURE OR lESS THAH 3 HILES TO NORK 1200. _HHUAL "ILEa
HULTI-CAR DIICDUKT -25X
............... DRIVER IHfORMATIOH ................
"'THE FOLLOWIHG MILL OPERATE VEHICLES COVERED 8V THIS PDLICY.
. STATE BIRTH HARITAL L1C
DRIVER ST L1CEHSE . DATE P/D SEX STATUI DATE
I LISA SRIHK PA 21114605 12101/51 P F H 02/67
2 KEHHETH SRIHK PA 266~7397 12/21113 PAS 17/11
3 THOHAS SRIHK PA 24665~97 01/27/76 PAS 09/92
... POLICYHOLDER HoTICES AHD POLICY INFORMATIOH ...
A22~60296 A21940194
IL09100101 AI7~II20~
A20750692 PPI3111211
28171299 Z9090391
A20790312
ST71711695
AI 9620990
AI 9020719
PAGE 02 ISSUE 11/01100 G~ I
A" I
PU 35 S4 21
OS-O~-Ol TO O'-I~-Ol
11-11-00
PJ0006E0095
PP0551111~
A22300315
...... POLICY ENDDRSEMEKTS AND POLICY fORMS .......
PPl~210.15 PP.~21.711 PPI~171'15 PP.~I.I711 PPl3J8.71.
PPOl510017 PP"'I"I~ PR.10..6t4 PPI3131411 PP'3.51...
PPIJ 11040'
.............. LOll PAYEE I ADDITIONAL INSURED ..................
-LOBI PAVEE- VEHICLES. I
AHERICAH GEHERAL FIHAHCE
1201 CARLISLE AD
VORK PA 17~0~
............. EHO OF POLICY DECLARATIOHS ..........
PREY FICHE 10 0205-007H"
PRIOR TERA 10
TIER ............. STAT ............. [MYALID
EXCPT TIER CLASS HULT PRF VIH vIH OT
01112H 00/00
81112" o~/oo
a&4L2M DO/DO
87102" DO/DO
USE AHTI
CHG OT THFT
0~11~100 I
0~11~100 I
04/14/00 I
)0111100 I
----IIVR---
STAT DATE
00100100
00100110
00100/00
PASS AHTI DEF DAY --DPR--DATE
REST LOCK ORV LAMP llC DT ADDED
5 1 9 10/01/99
5 1 9 10/25/99
3
9
03/30/00
5
9
111/11/00
---OTC---- -AOV OTC--
STAT DATE STAT DATE
00/00/00
00/00/00
00/00/00
--DATE--
ADDED
06/04/99
07/25/00
111/11/00
PREV FICHE 10 0205-007H'9
PRIOR TERH 10
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LAW OFFICES
KARL E. ROMINGER, Esq.
MARK F. BAYLEY, ESQ.
1SS SOUTH HANOVER STREET
CARLISLE, PENNSYLVANIA 17013
TEL: 717.241.6070
FAX: 717.241.6878
laW@romingerlaw.com
www.romingerlaw.com
March 29,2002
RE: OUR CLIENT: MATTHEW BRINK, a minor
YOUR INSURED: Li3a and Thomas Brink
CLAIM NUMBER: MO 12171 I WD
DATE OF LOSS: 10/14/00
~
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Ann Pilla
Sr. Claims Specialist
Harleysville Insurance
P.O. Box 1016
Moorestown, NJ 08057-0916
Dear Ann:
I am in receipt of your March 15, 2002 letter and the certified copy of the policy. We
appreciate ~1I of your efforts in this matter.
I have reviewed the packet which you provided me with, and I note that while my client
opted not to carry uninsuredlunderinsured coverage in 1997, that she did opt to carry the same in
1999 and did not waive stacking. Therefore, the policy printout as it now displays unstacked is
most likely incorrect.
It is therefore our position that the applicable policy limit for uninsured/underinsured is
15,000/30,000 with stacking for each vehicle owned at the time of the accident. I believe that the
Brinks had five (5) vehicles at the time of the accident, although it could have possibly been
four (4).
You indicated that you would be seeing if there were any other sign downs. If there are,
please caIl them to my attention immediately. Otherwise, I wiIllook for your confirmation
indicating that there is in fact stacked coverage available, along with your company's position on
how many vehicles the Brinks owned in October of2000, which would be the basis for a
multiplier of this coverage.
E~hibit. \\ E1"
ADVOCACY ADVICE ANSWERS
Ann Pilla
Sr. Claims Specialist
2
March 29, 2002
Finally, I would ask that you state whether or not you would waive subrogation, given the
increased coverage applicable, and give consent to settle at our discretion.
Sincerely,
-'-"'"
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Karl E. Rominger, Esquire
KER:ljj
cc. Mr. and Mrs. Thomas Brink
.. '" "
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....
HarleysVllle.
Good people to know
April 9, 2002
Karl E. Rominger
Rominger Law Offices
155 South Hanover Street
Carlisle PA 17013
RE: Your client:
Our Insured
Claim #
Datelloss
Dear Mr. Rominger:
MidAtlantic Claims Service'Center
Office Address Mailing Address
308 Harper Drtve. Suite 200 P.O. Box 1016
Moorestown, NJ Moorestown, NJ
08057-3245 08057-0916
jp
J../!;,)rz/
(888) 595-9876 Fax (856) 642-1699
www.harlevsvil1earouD.com
Matthew Brink, a minor
Lisa & Thomas Brink
MO 121711 WD
10/14/00
This will serve to acknowledge your letter of March 29, 2002. Be advised
I have referred this matter to our Home Office for further review. I will contact
you shortly concerning our position regarding coverage once a decision has
been reached.-
Sinc~~c ta
Ann Pilla
Sr. Claims Specialist
1 888 595 9876 x 2346
Exhibit \If 1."
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK, a minor
No.
AFFIDAVIT OF CONSENT
AND NOW, comes Tom and Lisa Brink, parents of Matthew Brink, DOB: December 3 I,
199 I, and requests that the Cumberland County Court of Common Pleas grant the Petition for
Leave of Court to Settle and Compromise Minor's Claim. This request is made as the parent
and legal guardian of Matthew.
Date:
1(7).0. 10:3
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Tom Brink
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IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS \ /
J~ 121103
IN RE: MATTHEW BRINK, a minor
No. 0 J - :U, '1::1
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AND NOW, this ~ day of-
ORDER OF COURT
Court to Settle and Compromise Minor
,2003, Petitioner's Petition/or Leave 0/
BY THE COURT,
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Distribution:
vXarl E. Rominger, Esquire >- f;::P-~l
....Ann Pilla, Claims Representative ~ I \
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IN RE: : IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
MATTHEW BRINK, a minor : 03-3693 CIVIL TERM
IN RE: HEARING DATE
ORDER OF COURT
AND NOW, July 29,2004, hearing on the Petition for Leave of
Court to Settle and Compromise Minor's Claim is set for 9:30 a.m. on
Wednesday, August 25, 2004, in Courtroom No.3; counsel for the petitioner
to notify all interested parties.
By the Court,
P.J.
~arl Rominger, Esquire
155 South Hanover Street
Carlisle, PA 17013
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IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
~
IN RE: MAllHEW BRINK, a minor
No. 03-3693
FINAL ORDER
tA
AND NOW, to wit this the 2 day of August, 2004, a hearing having been
held in this matter, it is hereby ordered that the compromise in the amount of Seven
Hundred Eighty One Thousand and Eight Hundred Dollars ($781,800.00) is approved.
The proceeds are to be distributed as follows;
(a) Two Hundred Fifty Thousand ($250,000.00) Dollars to be placed into
a structure and held and paid for the benefit of Matthew Brink pursuant to the
schedule outlined in Exhibit (0) of the original petition;
(b) One Hundred Thousand ($100,000.00) Dollars to be award to Tom and
Lisa Brink, parents of the minor child, to be used as they see fit, including for the
purchase of a handicap accessible home and 1 or remodeling to their current home,
or for other necessities, and also to defray the costs associated with work Lisa
Brink has given up to support the child;
(c) Two Hundred Eleven Thousand and Eighty Six ($211,086.00) Dollars
as a fee pursuant to a fee agreement signed with attorney Karl E. Rominger, and
for the many hundreds of hours spent on the case;
(d) Fifty Six Thousand Seven Hundred Twenty Three and Sixty Four One
Hundredth( $56,723.64) to satisfy the lien held by the Commonwealth of
Pennsylvania, for medical payments made on Matthew's behalf;
(e) Four Thousand Four Hundred Seventy ($4,470.00) Dollars to EBI, Inc.
for the cost of an electrical stimulator device which was supplied for necessary
medical treatment, but for which payment was defelTed pending this litigation;
(t) One Hundred Fifty Eight Thousand, SeVlm Hundred Twenty and 36
one hundredth ($158,720.36) Dollars to be placed in an account(s) which is
federally insured and interest bearing and 1 or said proceeds to be held in trust by
the Trust Department of a federally insured institution, and said proceeds only to
be invested in federally insured or 1 or guaranteed instruments, and further to be
held until further Order of Court, or age 18, and otherwise managed in accordance
with the Rules of Civil procedure, ~ ve.~V'W\ ~t to
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WJrt.
All sums set forth above shall constitute damages on account of personal
injuries, arising from an occurrence, within the meaning of ~ 104(a)(2) of the
Internal Revenue Code of 1986, as amended.
It is further ordered that the institution(s) in which said funds are deposited
are hereby granted permission to use the income from said funds that is necessary
to pay income tax which may become due and payable as a result of said funds
being managed by the institution. In addition the Tmst department of said
institution(s) shall be paid there normal and customary fee(s) as well as customary
charges for the preparation of federal and 1 or state tax returns or fiduciary returns.
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IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK. a minor
No. 03-369:1
AMENDMENTS AND ADDffiONS TO PETITION FOR LEAVE OF COURT
TO SETTLE AND COMPROMISE MINOR'S CLAIM
Pursuant to Pa. R.C.P. No. 2039(a), Petitioners, by and through their attorney, Karl E.
Rominger, Esquire, petitions this Honorable Court for leave to sClttle and compromise a personal
injury claim of Matthew Brink, a minor, and respectfully amends and adds to the Petition for
Minor Settlement previously filed and avers as follows:
1. The Department of Public Welfare has agreed to accllpt $56,723.64 to satisfy the total
lien amount due, recognizing a twenty-seven percent (27%) reduction from
$76,419.44 for the attorney's fees incurred. (Exhibit '''A'')
2. The Joint Tortfeasor Release between the parties, and involving Everett Cash Mutual
which was originally attached as Exhibit "G" is amended and changed and we ask
that the Court strike the first page of Exhibit "G" from the original Petition, and
replace it with Exhibit "G2", hereto attached.
3. Further, a copy of a Fee Agreement is attached between the parties and the parties'
lawyer, Karl E. Rominger, Esquire as Exhibit B to this Petition.
4. Further, EBI, Inc has an outstanding bill for $4,470.00 for a medical device used in
the treatment of Matthew, for which payment must be made.
5. A proposed final order is attached hereto.
WHEREFORE, Petitioners respectfully request that this Honorable amend and add to
the original Petition as stated above.
Date!?v92 r lOb'!
r I
Respectfully submitted,
ROMINGER, BAYLEY & WHARE
~d~Oming~, ~squire
155 South Hanover Street
Carlisle, PAl 70 I3
(717) 241-6070
Supreme Court ill # 8 I 924
Attorney fOlr Petitioners
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK. a minor
No. 03-369;~
AMENDMENTS AND ADDmONS TO PETITION FOR LEAVE OF COURT
TO SETTLE AND COMPROMISE MINOR'S CLAIM
CERTIFICATE OF SERVlCl!;
I, Karl E. Rominger, Esquire, attorney for Petitioners, do hereby certify that I this day
served a copy of the Amendments and Additions to Petitionfor Leave of Court to Settle and
Compromise Minor's Daim upon the following by depositing same in the United States Mail,
first class postage prepaid, at Carlisle, Pennsylvania, addressed as follows:
Cheryl Cox
Traveler's Insurance
P.O. Box 13485
Reading, PA 19612-3485
Robert Hotchkiss
Claims Department
Nationwide
P.O. Box 2655, 1000 Nationwide Dr.
Harrisburg,PA 17110
Erie Insurance Group
Brenda Schambach
Claims Adjuster
4901 Louise Drive, P.O. Box 2013
Mechanicsburg, P A 17055-0710
Jim Rhodes, VP Claims
Everett Cash Mutual Insurance Co.
P.O. Box 347
10591 Lincoln Highway
Everett, PA 15537
Via Fax: 814-623-0758
Scott Erney
Claim Specialist
State Farm Insurance
115 Limekiln Rd., P.O. Box 257
New Cumberland, P A 17070
Dated: 4- u9 2 F 2 GOy
t' /
Respectfully submitted,
ROMINGI~R. BAYLEY & WHARE
:;/~--
Karl E. Rominger, Esquire
155 South Hanover Street
Carlisle, PA 17013
(717) 241-6070
Supreme Court ID # 8 I 924
Attorney for Petitioners
AUG. 182004 131PM
NO. 0168
P. 2
.
CQl.4MONWEAL'TM OF PENNSY1.VANIA
DEPART~T OF PUBue WEt..FARI!
Bl.IRIiAU OF F1Jr4ANCIAl OPEAATIONS
DMSION OF TliIRD PARTY UABILlTV
CASVALlYU~IT
P.O.BOX 84S6
......RRISBUM. PA 17105-&188
August 18. 2004
ROMINGER & BAYLEY LAW OFFICES
IQ>JU. E ROMINGER ESQUIRE
155 S Ill\NOVER ST
CARLISLE PA 17013
Re, MAT'I'HIlW BRINK ("inor)
CIS #, 450133547
Incident Date, 10/14/2000
Dear Mr. Rominger,
The Department of public Welfare maintains a H.", in the amount of
$76.419.44 for the above-referenced incident.
The Department has agreed to reduce its lien by 11! acd accept the net
payment of $56.723.64 to satisfy the total lien amount.
Checks should be made payable to the Department of Public Welfare and
sent to my attention at the above address. We requ,eist that. with all
transmittal of funds, you provide the Department with a copy of the final
dhtribution sheet.
In the event you have already brought or will bring any action resulting
in a further recovery, we reserve the right to seek recovery of any
additional unpaid portion of our medical/cash lien. Thia settlement in no
way affects our future rights.
Thank you for your cooperation in this matter. If you have any further
questions, please co~tact me.
Sincerely.
~~c.-~~. (~u.pl)
Jessica L. Bupp
TPL Program Investigator
717-772-661.7
717-772-6553 FAX
.ff
POWER OF ATTORNEYIFEE AGlREEMENT
I/We, the undersigned, do hereby appoint KARL E. ROMINGER, ESQUIRE, my/our attorney
to institute and maintain an action against ROBERT STEINHOLR and ALL RESPONSIBLE
PARTIES, to recover damages for personal injuries sustained by our minor child MATTHEW BRINK
on or about the 10th day of October, 2000, or to effect an amicable settlement if possible.
I/We further agree that from whatever sum is obtained, either by my/our said attorney or by
me/us from the above-named defendant, either by way of settlement or verdict, my/our said attorney
shall receive twenty seven percent (27%) if no suit is filed and thirty-three percent (33%) thereoffor
professional services if a complaint or writ need be filed, and said attorney shall in addition thereto be
reimbursed for all documented expenses advanced in furtheranc(: of my/our case.
l/We further agree to advance to KARL E. ROMINGER, ESQUIRE, the costs of obtaining
medical and hospital records and expert opinions to determine the feasibility of maintaining such an
action. However, this procedure shall only be implemented upon approval of client, after discussion of
such with KARL E. ROMINGER, ESQUIRE.
I/We further agree that in the event an offer of settlement is made which my/our attorney
recommends that I/We accept, but which I/we reject, I/we agree to advance to KARL E. ROMINGER,
ESQUIRE, all costs which said firm is required to expend in cmmection with the preparation for and the
trial of this case.
This Power of Attorney, being made with an interest, is irrevocable and shall not be affected by
the death, disability or incapacity ofthe principal.
Should no money be recovered by suit or settlement, said attorney shall have no claim against
me/us of any kind for services rendered.
IN WITNESS WHEREOF, I/we have hereunto set my/our hand(s) and seales) this 24th day of
January, 2001.
WITNESS:
r L ,_ ~ J I? ~~!1
Tom Brink parent of Matthew Brink
c:I~l f3A~;J&
Lisa Brink parent of Matthew Brink
B
JOINT TORTFEASOR RELEASE AND SETTLEMENT AGREEMENT
This Joint Tortfeasor Release and Settlement Agreement is entered into between Thomas
S. Brink and Lisa A. Brink as guardians of Mathew Brink and Thomas S. Brink and Lisa A.
Brink, in their individual capacities as the insured and indemnifi(~d of Everett Cash Mutual on
this day of 2004.
I. RECITALS.
On or about October 14, 2000, the minor child, Matthew S. Brink was injured in a
bicycle/motor vehicle accident in Newburg, Cumberland County, Pennsylvania. Releasee was
the indemnified of the homeowner policy insurer of Thomas S. and Lisa A. Brink at the time of
the accident. Subsequent to the accident, Releasors made a claim for injuries and damages
which were sustained by them and their minor child as a result of said accident, and alleged that
said damages and injuries were caused by the acts and/or omissions of Releasee, or those
Releasee may have been required to indemnify, and others, including Robert W. Steinour, Sr.
and Daniel Hershey Auctioneering Service.
Releasors and Releasee have agreed to the terms and conditions of this Release in order
to settle, compromise, and discharge fully all claims and actions which Releasors have alleged
against Releasee on account of injuries and damages arising out of the bicycle/motor vehicle
accident of October 14, 2000.
II. TERMS AND CONDmONS.
(1) Warranty of Capacity
The Releasors represent and warrant that no other person or entity other than themselves
have or have had any interest in the claims, demands, obligations or causes of action referred to
G-L
IN THE CUMBERLAND COUNTY COURT OF' COMMON PLEAS
IN RE: MATTHEW BRINK, a minor
No. 03-3693
FINAL ORDER
AND NOW, to wit this the _ day of August, 2004, a hearing having been
held in this matter, it is hereby ordered that the compromise in the amount of Seven
Hundred Eighty One Thousand and Eight Hundred Dollars ($781,800.00) is approved.
The proceeds are to be distributed as follows;
(a) Two Hundred Fifty Thousand ($250,000.00) Dollars to be placed into
a structure and held and paid for the benefit of Matthew Brink pursuant to the
schedule outlined in Exhibit (0) ofthe original petition;
(b) One Hundred Thousand ($100,000.00) Dollars to be award to Tom and
Lisa Brink, parents of the minor child, to be used as, they see fit, including for the
purchase of a handicap accessible home and 1 or remodeling to their current home,
or for other necessities, and also to defray the costs associated with work Lisa
Brink has given up to support the child;
(c) Two Hundred Eleven Thousand and Eighty Six ($211,086.00) Dollars
as a fee pursuant to a fee agreement signed with attorney Karl E. Rominger, and
for the many hundreds of hours spent on the case;
(d) Fifty Six Thousand Seven Hundred TWI:fity Three and Sixty Four One
Hundredth( $56,723.64) to satisfy the lien held by the Commonwealth of
Pennsylvania, for medical payments made on Matthew's behalf;
(e) Four Thousand Four Hundred Seventy ($4,470.00) Dollars to EBL Inc.
for the cost of an electrical stimulator device which was supplied for necessary
medical treatment, but for which payment was deferred pending this litigation;
(f) One Hundred Fifty Eight Thousand, Seven Hundred Twenty and 36
one hundredth ($158,720.36) Dollars to be placed in an account(s) which is
federally insured and interest bearing and 1 or said proceeds to be held in trust by
the Trust Department of a federally insured institu1ion, and said proceeds only to
be invested in federally insured or 1 or guaranteed instruments, and further to be
held until further Order of Court, or age 18, and otherwise managed in accordance
with the Rules of Civil Procedure.
c~ (
All sums set forth above shall constitute damages on account of personal
injuries, arising from an occurrence, within the meaning of ~ 104(a)(2) of the
Internal Revenue Code of 1986, as amended.
It is further ordered that the institution(s) in which said funds are deposited
are hereby granted permission to use the income from said funds that is necessary
to pay income tax which may become due and payable as a result of said funds
being managed by the institution. In addition the Tmst department of said
institution(s) shall be paid there normal and customary fee(s) as well as customary
charges for the preparation of federal and 1 or state tax returns or fiduciary returns.
By the Court,
Hon. George E. Hoffer J.
C -2
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK, a minor
No. 03-3693
~ ee-krl1 .....,
~
AND NOW, this Ll If day ofFebruary, 2005, pursuant to the August 25, 2004, Order of
Court a return is filed as follows:
A. RECEIPTS
(A) Nationwide Insurance $600,000.00
(B) State Farm Insurance $100,000.00
(C) Travelers Insurance $ 60,000.00
(D) Erie Insurance $ 17,000.00
(E) Everett Cash Mutual $ 4.800.00
Total $781,800.00
B. DISBURSEMENT
(A) Structured Settlement through Nationwide Insurance $250,000.00
(B) Payment to parents, Tom and Lisa Brink $100,000.00.
(C) Attorney's fees, Rominger, Bayley & Whare. $211,086.00
(D) Department of Welfare to satisfy lien $ 56,723.64
(E) EBI Inc., for an electrical stimulator device
$ 4,470.00
$159.520.36
(F) Trust Account at Orrstown Bank
TOTAL
$781,800.00
C. MONIES THAT REMAIN
$
00.00
Date: 2 ~ 2 / - (; f-
Respectfully submitted,
ROMINGER. BAYLEY & WHARE
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Karl E. Rominger, Esquire
155 South Hanover Street
Carlisle, PA 17013
(717) 241-6070
Supreme Court ill # 81924
Attorney for Petitioner
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IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK, a minor
No. 03-3693
PETITION TO RELEASE FUNDS TO MINOR
Now comes Petitioner, Lisa Brink, parent and Natural guardian of Matthew
Brink, a minor, by and through her attorney, Karl E. Rominger, Esq., and avers as
follows:
1. A settlement was reached by the parties on August 25, 2004.
2. In accord with said settlement, the Honorable George B. Hoffer of the
Cumberland County Court of Common Pleas ordered the funds from the settlement to
be placed in a sequestered deposit account and not to be drawn upon until the minor,
Matthew Brink, reaches the age of 18. Attached hereto as 'Exhibit A'
3. Matthew Brink will turn the age of 18 on December 31, 2009.
4. The funds from this settlement are held at Orrstown Bank in Carlisle,
Pennsylvania.
5. Petitioner seeks to withdraw $8288.00 at said bank, in order to have a
ramp built for the minor, Matthew Brink as he is having surgery on June 9, 2006, on his
left leg that was crushed in the accident and in order to have an air conditioner installed
for the benefit of and the comfort and the well being of the minor. Estimates for the
ramp and air conditioner are attached as Exhibit "B".
6. Affidavit of the mother is attached and incorporated herein, the minor's
father is currently incapacitated due to health reasons.
~
WHEREFORE, Petitioners ask this Honorable Court to enter an order releasing
said funds.
ATfORNEY'S FEES
7. Petitioners have retained the law firm of Rominger & Whare to have the
funds released.
8. Karl E. Rominger, Esquire is counsel of record and has worked on this
Petition at an hourly rate of $175.00 per hour.
9. Thus far, 2.4 hours have been spent on this case by the Attorney
Rominger.
10. Rominger and Whare seek attorney fees paid from the Minor's funds at
Orrstown Bank.
11. Petitioners have concurred with this agreement.
WHEREFORE, Petitioners and Counsel ask this Honorable Court to Order
attorney fees be withdrawn and directed to be paid to the law firm of Rominger &
Whare, in the amount of $420.00.
Date:!>~y2 ~ 20()'
Respectfully Submitted,
ROMINGER & WHARE
7.
Karl E. Rommger
155 South Hanover Street
Carlisle, PA 17013
(717) 241-6070
Supreme Court ID # 81924
Attorney for Petitioner
,
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK, a minor
No. 03-3693
AFFIDAVITS
I, Lisa Brink, as the parent and natural guardian of Matthew Brink, a minor, do
believe and hereby affirm that the released funds from Orrstown Bank will be used
solely to have a ramp built and to install air conditioning for the minor child, Matthew
Brink. I believe it to be in the child's best interest.
I verify that I am the petitioner and that the statements made in the foregoing Petition are
true and correct. I understand that false statements herein are made subject to the penalties of 18
Pa. C. S. ~ 4904, relating to unsworn falsification to authorities.
d~J3~
Lisa Brink
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Proposal
Specification and Estimate
No. 1
Page of Pages
" Ii'RO E'i"E..RG';-
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230 Uncolnway East
New Oxford., PA 17350
Ray Etzler
717;'624~58G-ci
800-998-4311
Heatll1g i'ill' Conditio-ri..'1g Sales Servi.ce
1IIID HVAC License #:. ~,m-tIVAC'-'J2 .1:Y;'5
Pro osal Submitted To
NAME Lisa & Thomas Brink
STREET 89 Country Estates
CITY.STAN~e, PA 17241
Location
PHONE 776-5106
DATE
02/02/06
JOB NAME
JOB L0CA11ON
ARCHITECT
DATE OF PlANS
ACcOUNTt 565426
JOB PHONE
". WE.HE!'leaYPROP~E T-O;~URNISH""'ATERIAt.S AND LABOR NECE~SARYFOR"THE'eOMP!-ETION OF:- ,.
Install a ~11iller 3 ton Split Air Condition System, condensor set on a pad, line set, "A" coil,
condensate dram, breaker, electrical \Vmng WIth an outdoor disconnect, and any matenal
needed to compiete the ~,allanon.
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2 year :tull warranty on parts and. labor.
:) years tactory warranty on the compressor.
Pleases1$l1and return white copyartd,payment optIon le.tt(ll" to our S~les Department
WE PROPOSE HEREBY to furnish materials and labor- complete in accordance with above specifications, for the sum
of:
Two Thousatlfl Six l:Iundred Nine apd 00/100
2,609.00
dollars ($
Payment to be made as
follows:
See attached letter
All material is gUBranteed to be as specified. All work to be completed in
a substantiBI workmanlike manner according to specifications submitted,
per standard practices. Any al~ratiOn or deviation from above
specifications involving extra cgstS will be executed only upon written
orders. and'will become an!lxtra Charge Qver and above the estimate. All
~gr.eements. contingent. uPon .. strikes, accidentsQr. delBysbeyond . our
contt!il; .Own"" 19canY fire, tornado and other necessary insurance. Our
workers. ara fyUy coV!lradby II'VOrkBr'S Compensation Insurance.
AuthOrlZed;J B;J, " r
Signature f.~ ~. ..\W./ r f H ,~
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I
Note:This proposal m$}i/\be withdrawn by us 'if
not accepted within ~ days.. .., ..
ACCEPTANCE OF PROPOSAL. The above prices. . Em,' bi+ It' ~\\
specifications, conditions, as well as Terms and Conditions on
the reverse side are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment will Signature
be made as outlined above.
Date of Acceptance
Signature
/
35 I rish Gap Road
Newville, PA 17241
Call
(717) 486-8016
Pl"o;(}~a.t Proposal Submitted To
Name ~ ~A:l1A(
Street @f Ct:)cJ"Vh-t (/,At) Est
City Vt.M/IlILt E.- State ~ Zip /7Z't I
Phone 77 Ie, -5/ D '='
Date .y- 'Z-O - (p
$~
t\f.N~l'"~
CONSTRUCTION
We hereby propose to furnish all the materials and perform all the labor necessary for the completion of
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Any alteration or deviation from above specifications involving extra costs, will be executed only upon written orders,
and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control.
Note -This proposal may be withdrawn by us if not accepted within
days.
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as
specified. Payment will be made as outlined above.
Accepted
Date
Signature
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IN RE: MATTHEW BRINK, a minor,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
No. 03-3693 Civil
ORDER OF COURT
AND NOW, this 1st day of June, 2006, after review of the Petition of the Guardian and
Natural Parent of Matthew Brink for Release of Funds to Minor, a hearing on the matter will be
held on Friday, July 7 at 2:30 p.m. in Courtroom No.5 of the Cumberland County Courthouse,
Carlisle, Pennsylvania. The minor child Matthew Brink will be required to testify at the hearing.
The Guardian shall be prepared to address the following concerns of the Court:
(1) An accounting of the $100,000.00 which was awarded to Thomas and Lisa Brink to
use as they see fit, including the purchase of a handicapped accessible home and/or
remodeling.
(2) The type and approximate current value of the residence in which the family is
currently residing.
(3) Whether or not Thomas and Lisa Brink own the real estate upon which these
improvements are to be made.
(4) The necessity for the 260 square foot deck in addition to the ramp.
By the Court,
krl Rominger, Esquire
Attorney for Petitioner
~
bas
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M. L. Ebert, Jr., ' J.
VJ
1:J'!N\;<!\lA.Si\JNJd
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80 :8 Jit' 1- Nnr 9UOl
N:N10iIJO:-:LOtid 3Hl.:JO
301.:1:10-(/31/:1
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK, a minor
No. 03-3693
ORDER TO CANCEL HEARING
AND NOW, this 1.. ~1~ day of ! \) to ( ,2006, upon request of
Petitioner, the hearing on the Petition to Release Funds which is scheduled for July 7,
2006, is hereby canceled and the requested relief is deemed withdrawn.
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10 :t; lid 62 inf SOul
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Karl E. Rominger, Esquire r° ° Tit E P R 0 T'F C y U _t `
Rominger&Associates WGINAL
PA Attorney License No. 81924
155 South Hannover Street CIUMBER AND COUNTY
Carlisle, PA 17013 ENNSYL'dANIA
(717) 241-6070
Fax (717) 241-6878
Attorney for Plaintiff
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK
Incapacitated Adult No. 03-3693
PETITION TO RELEASE FUNDS HELD IN ESCROW TO INCAPACITATED
NOW COMES Petitioner,.Mathew Brink, an incapacitated adult individual,by and
through his Attorney Karl E.Rominger, Esquire with the Law Firm of Rominger & Associates,
and avers as follows:
1. A settlement was reached on August 25, 2004 in a lawsuit brought by Petitioner
after an automobile accident, which left Petitioner incapacitated and unable to handle his own
financial affairs on August 25, 2004.
2. Petitioner was adjudicated incapacitated and by order of the Court dated February
26, 2010 Petitioners mother, Lisa Brink and his father Thomas S. Brink were appointed as
Petitioners personal guardian, and Orrstown Bank was appointed guardian of petitioner's
financial estate.
3. Petitioner's father died on December 16, 2010.
4. The February 26, 2010 Order provided that funds held in escrow for Petitioner
shall not be released without an order of the court.
5. The funds from this settlement are held at Orrstown Bank in Shippensburg,
Pennsylvania.
6. Petitioner seeks the release of$3592.00 from the said Trust.Account held at
Orrstown Bank, in order to pay the following expenses:
Payment of past due 2013 monthly lot rent from January 2013 to December, 2013 lot rental for
the trailer situated at Country View Estates, Lot#89 in Newville, Cumberland County,
Pennsylvania at $289.00 per month plus late fees for a total past due for 2013 in the amount of
$3,592.00 which is now in arrears.
ATTORNEY'S FEES
7. Petitioners have retained Attorney Karl E. Rominger, Esquire with the law firm of
Rominger&Associates, 155 South Hanover Street, Carlisle, PA 17013 to Petition the Court to
have the funds released and to assist with other legal matters as necessary from time to time.
8. Attorney Karl E. Rominger has performed various legal duties in representing
Petitioner as set forth in the attached bill in the amount of$500.00
Attorney Karl E. Rominger, Esquire has worked on this Petition and other legal matters
for Petitioner as set forth in the attached bill as Exhibit B at an hourly rate of$250.00 per hour.
9. Attorney(s) seek attorney fees paid from the Trust funds at
Orrstown Bank in the amount of$500.00
10. Petitioners have concurred with this agreement.
WHEREFORE, Petitioner and Counsel ask this Honorable Court to Order funds from the
,Trust Fund held on Petitioners behalf at Orrstown Bank to be released to pay the above stated
expenses in the amount of$3,592.00 for County View Estates and $500 for Karl E. Rominger,
Esquire.
Respectfully Submitted,
ROMINGER& ASSOCIATES
Date:
Karl E. Rominger, Esquire
Attorney for Defendant
155 South Hanover Street
Carlisle, PA 17013
Supreme Court ID# 81924
(717) 241-6070
Karl E. Rominger, Esquire
Rominger&Associates
PA Attorney License No. 81924
155 South Hannover Street
Carlisle, PA 17013
(717) 241-6070
Fax (717) 241-6878
Attorney for Plaintiff
IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS
IN RE: MATTHEW BRINK
No. 03-3693
CERTIFICATE OF SERVICE
1, Karl E. Rominger, Esquire, certify that I this day served a copy of the within Petition
upon the following by depositing the same in the United States Mail, postage pre-paid, via first
class, addressed as follows:
Lisa Brink, Personal Guardian
89 Country View Estates
Newville, Pennsylvania 17241
Orrstown Bank
Attn: Daniel K. Baer, Trust Officer
P.O. Box 250
Shippensburg, Pennsylvania 17257
Respectfully Submitted,-
ROMINGER& ASSOCIATES
Date: --•----
Karl E. Rominger, Esquire
Attorney for Defendant
155 South Hanover Street
Carlisle, PA 17013
Supreme Court ID# 81924
(717) 241-6070
Cou nt ry �
View 2013
E S T A T E S B Y MAY o �;
..............
^!A
Notice of Eviction
May 1, 2013
Lot 89 CVE
Newville, PA 17241
Attention: Matthew Brink, Thomas Brink, Lisa Brink:
You are being evicted from Country View Estates for non-payment of rent. Your
balance of rent plus late charges of one dollar per day total $3,592.00 as of May
1 St (For the year 2013). The amount must be received in full on or before June 1 St
or 30 days from the date of this letter. If this amount has not been received by
June 1 st your eviction will be filed with the local district justice. A letter was sent
to your attorney asking for funds back in December and January as per our
agreement back in December 2011. No funds have been forwarded to
continue your lease. You have 30 to remove your home and possessions from
loft 89 Country View Estates.
Sincerely,
Brooke Finkenbinder
Manager Country View Estates
PO Box 175 Newville,PA 17241 Phone: (717) 776-9764
Rominger & Associates
155 South Hanover Street
Carlisle, PA 17013
Ph:(71 7) 241-6070 Fax:(717) 241-6878
Mathew Brink June 3, 2013
c/o Orrstown Bank
P.O. Box 250
Shippensburg, PA
17257 USA
File#: 9574-002
Attention: Inv #: 3319
Billing Memo
RE: RE: Matthew Brink
Docket No No. 03-3693
DATE DESCRIPTION HOURS AMOUNT LAWYER
May-30-13 Draft Petition and file in Court. Contact 2.00 500.00. ker
County View regarding rent.
Totals 2.00 $500.00
Total Fee & Disbursements $500.00
Balance Now Due $500.00
TAX ID Number 26-0043268
IN THE CUMBERLAND COUNTY COURT OF COMMONTLBA
I 4 —6 V 3
CUMBERLAND COUNT','
IN RE: MATTHEW BRINK
Incapacitated Adult No. 03-3693PENNSYLVANIA
IN RE: PETITION TO RELEASE FUNDS HELD IN ESCROW TO INCAPACITATED
ADULT
ORDER OF COURT
k�
AND NOW,this - day of ��he, , 2013 ,upon Motion of Karl E.
Rominger,Esquire and the Law Finn of Rominger&Associates, and upon consideration of the Petition
to Release Funds Held in Escrow for Incapacitated Adult,Financial Guardian, Orrstown Bank, is hereby
ordered to release funds held in trust in ordered to pay the expenses and legal fees set forth in Petitioner's
Petition set forth as follows:
(a). Payment of past due 2013 monthly lot rent from January 2013 to December,2013
lot rental for the trailer situated at Country View Estates, Lot#89 in Newville, Cumberland
County,Pennsylvania at$289.00 per month plus late fees for a total past due for 2013 in the amount of
$3,592.00 which is now in arrears.
(b). Attorneys fens payable to Karl E.Rominger, Esquire for$500.00.
The total amount to be released from the Trust Fund held on Petitioner's behalf at
Orrstown Bank to pay the above stated expenses in the amount of$3,592.00 for County View
Estates and$500.00 for Karl E. Rominger, Esquire
By the Court
J.
Di s ribution
Karl E Rominger,Esquire,Rominger&Associates, 155 South Hannover Street, Carlisle,Pennsylvania
1013
Lisa Brink; 89 Country View Estates,Newville,Pennsylvania 17241
/niel K.Baer,Trust Officer, Orrstown'Bank,P.O. Box 250, Shippensburg,Pennsylvania 17257
LAC.,
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