HomeMy WebLinkAbout03-6660SHIPPENSBURG/
SOUTH HAMPTON MANOR, LP
Plaintiff
DOROTHY REED and
RAY REED,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2003- 6,6 doO CIVIL TERM
CIVIL ACTION-LAW
NOTICE
You have been sued in corm. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this complaint and notice are
served, by entering a written appearance personally or by an attorney and filing in writing with
the court, your defenses or objections to the claims set forth against you. You are warned that if
you fail to do so, the case may proceed without you and a judgment may be entered against you
by the court without further notice for any money claimed in the complaint or for any other
claim or relief requested by the plaintiff. You may lose money or property or other rights
important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH iNFORMATION
ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE
TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER
LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
SHIPPENSBURG/
SOUTH HAMPTON MANOR, LP
Plaintiff
DOROTHY REED and
RAY REED,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2003- (, ~ ~ O CIVIL TERM
CIVIL ACTION-LAW
COMPLAINT
NOW, comes Shippensburg/South Hampton Manor Limited Partnership ("Shippensburg
Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within
Complaint and, in support thereof, sets forth the following:
1. Shippensburg/South Hampton Manor Limited Partnership is a Maryland limited
partnership duly authorized to conduct business in the Commonwealth of Pennsylvania.
2. Defendant, Dorothy Reed, is an adult individual with a residence address of 121
Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
3. Defendant, Ray Reed, is an adult individual with a residence address of 1817
West Heishman Gardens, Carlisle, Pennsylvania.
4. Shippensburg Health operates a resident skilled nursing facility (the "facility")
located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
5. On or about May 28, 2003, Ray Reed sought to have Dorothy Reed, his wife,
admitted to the Shippensburg Health facility.
6. On or about May 28, 2003, Ray Reed executed a Patient Data and Consent Form
in connection with having Dorothy Reed admitted to the facility. A true and correct copy of the
Patient Data and Consent Form is attached hereto as Exhibit "A" and is incorporated by
reference.
7. Pursuant to the Patient Data and Consent Form, Ray Reed and Dorothy Reed
agreed to pay for the costs of care not covered by third party payors.
Dorothy Reed became a resident of the facility on or about May 28, 2003 and
remains a resident to the date of this Complaint.
9. During her residency at the facility, costs have been accruing for services
provided by Shippensburg Health to Dorothy Reed.
10. As of November 25, 2003, there remains due and owing the sum of $9,221.10 on
the account of Dorothy Reed in accordance with the Statement attached hereto as Exhibit "B"
and incorporated by reference.
11. The amount due and owing reflects costs of necessaries as provided by
Shippensburg Health to Dorothy Reed.
12. Demand has been made upon Dorothy Reed and Ray Reed to pay the amount due
and owing.
COUNT I-BREACH OF CONTRACT
SItIPPENSBURG HEALTH v. DOROTHY REED and RAY REED
13. Plaintiff incorporates by reference paragraphs one through twelve as though set
forth at length.
14. All conditions precedent to recovery have been fulfilled.
15. Dorothy Reed is obligated to pay the costs of her care provided by Shippensburg
Health which were are not covered by a third party payor.
16. The costs set forth on Exhibit "B" are not covered by a third party payor.
17. Dorothy Reed has, without justification, failed and refused to pay the amount due.
18. At all times relevant hereto, Ray Reed has been the spouse of Dorothy Reed.
19. As the spouse of Dorothy Reed, Ray Reed is bound to pay for necessaries
provided to Dorothy Reed. The care and services provided by Shippensburg Health to Dorothy
Reed are necessaries.
Ray Reed has, without justification, failed and refused to pay the amount due.
Dorothy and Ray Reed have breached the agreement to pay for the costs of care
20.
21.
provided.
WHEREFORE, Plaimiff requests judgment in its favor and against the Defendants for
the sum of $9,221.10, interest, costs, expenses and any additional amount coming due to the date
of award.
COUNT II-QUANTUM MERUIT
SHIPPENSBURG HEALTH v. DOROTHY REED
22. Plaintiff incorporates by reference paragraphs one through twenty-one as though
set forth at length.
23. During the period of her residency at the facility, Dorothy Reed has enjoyed the
benefit of care and services provided to her by Shippensburg Health.
24. Dorothy Reed has failed and refused to pay for the costs of her care and services
provided by Shippensburg Health.
25. Dorothy Reed has been unjustly enriched by her use and enjoyment of the
services and care provided by Shippensburg Health without making payment therefor.
WHEREFORE, Plaintiff requests judgment in its favor and against Dorothy Reed for the
sum of $9,221.10 plus costs, interest and expenses.
Respectfully submitted,
~'BRIEN, BARIC & SCHERE~
David A. Baric, Esquire
I.D. 44853
17 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/reed/complaint.pld
12/17/2883 17:37 7172495755 OBS PAGE 07
VERIFICATION
The statements in the foregoing Complaim axe ba~ed upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the statements; and to the extent that th~j axe based Ul~On information which I have
given to my counsel, they are true and correct to the b~st of my knowledge, information and
bclief. I und~rsland that fal.e statements her~in are made subject to the penalties of 1 $ Pa.C.8. §
4904 relating to unswom falsifications to authorities.
DATIB: .~jL~
SHIPPENSBURG HEALTH CARE CENTER
PATIENT DATA ANb CONSENT FORM
q
Nanm: ~"~O~fO-~-~ '~..~,,;[ Soc. Sec.~: ~Ol~'~-tq~ Date:
Address: i%~q ¢~. ~~k~ City: ~t[~[~ State: ~
Zip Code: [q~ Male ~mal~ Date or Birth:
Marital Status: Single ~ Separated Divorced Widowed
Primary Insurance: ~ ("~
Policy Number: LOC IGI 14~ Iq,'°~
INSURANCE
Policyholder:
Group Number:
Relationship:~
Secondary Insurance:
Policyltoldcr: Relatiol~sbip:.
Policy Nnmbcr:
MEDICARE#: C'~ ~
Group Nnmbcr:
MEDICAID#:
RESPONSIBLE PARTY
Name: {~CI.x:.._~ (~o¢.-C.( Relationship:
Referring Physician:
Primary Care Physiciau:
Treating Diagnosis:
Sca'icc Requested:
Occupational Therapy
Prinmry Diagnosis:
Physical Therapy
Spccch Thcrapy
Patient's aud/or fanlily's permission to bill and consent to receive treatment, release information and make payment.
Under Mcdicare Part B (a National Health Program through which certaiu medical and hospital cxpcnses arc paid
from Federal Funds) you must meet the following conditions: 1. You must satisfy your deductible.
2. Medicare will puy 80% of the charge ,'filer the deductible has been satisfied up to a maximuln annual
cap.
3. Thc 20% unpaid balance and/or amounts above the annual cap will be billed to you or the person
responsible for payiug yonr bills.
4. lf.',ou have a Tic-in Plan or other insurance that x~ill pay the balance wc will submit thc bill to them.
5. This form must be signed by you or your family giving us permission to (1) bill 80% to Medicare and
(2) 20% (Co-pay), and amounts above the annual cap, and any deductible not already satisfied, to you
or )'our insurance Conlpluly.
6. For patients who arc Medicaid and Medicare Part B and decreed iadigcnt, thc Facility will accept
assigmnent pursuant to state laws aud regulations.
I authorize trcaUnent and payment of medical benefits to file Facility for services rendered as ordered by my
physician. I further authorize file Facility to furnish medical or other information for any claims iucurred for a
period of one year under the Title XVIII of the Social Security Act and its intermediary. I hereby accept all
responsibility for treatment costs not covered or rdmburscd by third party payers.
i~,naturedof Patient or Authorized Representative
EXHIBIT UA"
Date
Witness (Signature)
STATEMENT P. 3
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG, PA 17257
Facility Phone: 717-530-8300
Resident: DOROTHY REED
RAY REED*
1817 A HEISHMAN GARDENS
CARLISLE, PA 17013
Date Service Through
Qty Description
10/01/03 05/28/03 05/31/03 8 Room Charges
10/01/03 05/20/03 06/29/03 5 Bed Hold-Room Cha~ges
10/01/03 06/01/03 08/30/03 25 Room Charges
10/01/03 07/01/03 07/01/03 1 Room Charges
Stmement Date: 11/25/03
Cash ReceiDts/'Adiustme nta
06/01/03 05/28/03 05/31/03
4 AD J, Room Charges
Sub Total
Balanoe
Sub Toter
Balance
Amount
2,072.00
1,295.00
6,475,00
259,00
10,101.00
10,101.00
-1.036.00
-1,0,36.00
9,065,00
AnclllerV/Qther Charoes
10/01/03 06/03/03 06/06/03
06/16/03 06/16/03 06/16/03
5 97535OT- ADL MANAGEMENT TRAINING
1 CABLE
Sub Total
Balance aa of: 11/26/03
Total Amount Due
149.10
7,00
156.10
9,221,10
9,221.10
EXHIBIT "B"
Page
~ SHERIFF'S RETURN -
CASE NO: 2003-06660 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
SHIPPENSBURG/SOUTH HAMPTON MAN
VS
REED DOROTHY ET AL
REGULAR
JASON VIORAL
Cumberland County,Pennsylvania,
says, the within COMPLAINT & NOTICE
REED DOROTHY
DEFENDANT , at 0915:00 HOURS, on the
at 1817 HEISHMAN GARDENS
CARLISLE, PA 17013
DOROTHY REED
a true and attested copy of COMPLAINT & NOTICE
Sheriff or Deputy Sheriff of
who being duly sworn according to law,
was served upon
the
12th day of January , 2004
by handing to
together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing 18.00
Service 3.45
Affidavit .00
Surcharge 10.00
.00
31.45
Sworn and Subscribed to before
me this /~ day of
~&~¥ A.D.
! ~rothonotary' ! ~,
So Answers:
R. Thomas Kline
ox/1~/2oo4
OBRIEN BARIC SCHERER
uty Sheriff
SHERIFF'S RETURN - REGULAR
CASE NO: 2003-06660 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
SHIPPENSBURG/SOUTH HAMPTON MAN
VS
REED DOROTHY ET AL
JASON VIORAL , Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according
says, the within COMPLAINT & NOTICE was served upon
REED RAY
DEFENDANT at 0915:00 HOURS,
at 1817 WEST HEISHMAN GARDENS
CARLISLE, PA 17013
DOROTHY REED, WIFE
a true and attested copy of COMPLAINT & NOTICE
the
on the 12th day of January , __
by handing to
together with
tO law,
2004
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing 6.00
Service .00
Affidavit .00
Surcharge 10.00
.00
16.00
Sworn and Subscribed to before
So Answers:
R. Thomas Kline
01/13/2004
OBRIEN BARIC SCHERER
By:
ty She~if f
SHIPPENSBURG/
SOUTH HAMPTON MANOR, LP,
Plaintiff
VS.
DOROTHY REED and
RAY REED,
Defendants
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: CIVIL ACTION
: NO. 2003 6660 CIVIL TERM
:
: CIVIL ACTION - LAW
:
: GURY TRIgL DEM/~DED
NOTICE
TO the Plaintiff:
You are hereby notified to plead to the enclosed New Matter
within twenty (20) days from service thereof or a default
judgment may be entered against you.
Dale F. Shug~'art
Attorney for Def,
lda~t s
SHIPPENSBURG/
SOUTH HAMPTON MANOR, LP,
Plaintiff
VS.
DOROTHY REED and
RAY REED,
Defendants
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: CIVIL ACTION
:
: NO. 2003 6660 CIVIL TERM
: CIVIL ACTION - LAW
: JURY TRIAL DEMANDED
ANSWER AND NEW MATTER
B_ND NOW, come the Defendants, Dorothy' Reed and Ray Reed, by
their attorney, Dale F. Shughart, Jr., Esquire, and file the
following Answer and New Matter in response to Plaintiff's
Complaint:
ANSWER
1. Admitted.
2. Admitted in part. Denied in part. Dorothy Reed is an
adult individual. She resides at 1817-A Heishman Gardens,
Carlisle, PA 17013.
3. Admitted in part. Denied in part. Defendant Ray Reed is
an adult individual. He resides at 1817-A Heishman Gardens,
Carlisle, PA 17013.
4. Admitted with a clarification. An entity known as
Shippensburg Health Care Center operates a skilled care facility at
the stated address. (emphasis added).
5. Denied. On the contrary, Defendant Dorothy Reed was a
resident in a skilled nursing care unit at York Hospital, as a
result of a medical condition diagnosed as Alzheimer's. Ray Reed,
husband of Dorothy Reed, undertook an effort, through Cheryl Bjorum,
Social Worker at York Hospital, to arrange for a transfer of his
wife to a location closer to their home. The Social Worker at York
Hospital arranged the transfer to Shippensburg Health Care Center,
which took place on May 28, 2003.
6. Admitted.
7. Denied. On the contrary, the document speaks for itself.
By way of further Answer Ray Reed signed the document on behalf of
Dorothy Reed, as her authorized representative. He did not assume
personal responsibility for her care. Additionally, Shippensburg
Health Care Center only accepted Dorothy Reed as their resident
after Mrs. Reed had been certified for 100% coverage through
Mrs. Reed's medical insurance as reflected upon the insurance
coverage verification obtained by Shippensburg Health Care Center
before agreeing to admit Mrs. Reed as a resident. True and correct
copies of the insurance coverage confirmation provided to
Defendants by Shippensburg Health Care Center and Mrs. Reed's
medical insurance card are attached hereto, made a part hereof and
marked Exhibits "C" and "D" respectively.
8. Admitted in part. Denied in part. Dorothy Reed became a
resident of the facility on May 28, 2003. She was discharged from
care, to her own home, on July 2, 2003.
9. Admitted in part. Denied in part~ It is admitted that
the costs were incurred for Mrs. Reed's care from May 28, 2003
through July 1, 2003. Mrs. Reed was discharged from
However,
Shippensburg Health Care Center to her home on July 2, 2003 and no
additional charges have been incurred for her care at the Center
since that time.
10. Admitted in part. Denied in part. It is admitted that
Plaintiff's Exhibit "B" is a copy of Shippensburg Health Care
Center's bill sent to Ray Reed in November 2003. As to the
remaining averments of Paragraph 10 of Plaintiff's Complaint,
Defendants are without knowledge or informa~sion sufficient to form
a belief as to the truthfulness of those averments and proof
thereof is demanded. By way of further Answer, Shippensburg Health
Care Center, as a participant in the Anthem Blue Cross/Blue Shield
Health Insurance Plan of Dorothy Reed,
the amounts authorized by Anthem Blue
care provided and to accept direct
Cross/Blue Shield.
11. Denied.
agreed to accept payment in
Cross/Blue Shield for the
payment from Anthem Blue
After reasonable investigation, the Defendants
are without knowledge or information sufficient to form a belief as
to the truthfulness of the averments of Paragraph 11, and proof
thereof is demanded. By way of further Answer, the averments of
Defendants' Answer to Paragraph 10 of Plaintiff's Complaint is
incorporated herein by reference thereto.
12. Admitted in part. Denied in Part. It is admitted that
the Shippensburg Health Care Center has submitted a bill,
Plaintiff's Exhibit "B", to the Defendants. It is denied that
Defendants owe any obligation to Plaintiffs. By way of further
--3-
Answer, the averments of Defendants'
Plaintiff's Complaint and Defendants'
therein by reference to.
Answer to Paragraph 10 of
New Matter are incorporated
COUNT I - BREACH OF CONTRACT
13. NO Answer required.
14. Denied. On the contrary, Shippensburg Health Care Center
accepted Dorothy Reed as a resident, and iDorothy Reed agreed to
become a resident, on the basis that the reasonable charges for
Mrs. Reed's care would be paid by Anthem Blue Cross/Blue Shield.
It is believed and therefore averred that the Shippensburg Health
Care's claim for payment was improperly submitted to Anthem Blue
Cross/Blue Shield, and Shippensburg Health Care failed to resubmit
proper documents after being notified that the original submission
was rejected.
15. Denied. On the contrary, the averments of Defendants'
other Answers to the Complaint and New Matter are incorporated
herein by reference thereto.
16. Denied. On the contrary, the averments of Defendants'
other Answers to the Complaint and New Matter are incorporated
herein by reference thereto.
17. Denied. On the contrary, the averments of Defendants'
other Answers to the Complaint and New Matter are incorporated
herein by reference thereto.
18. Admitted.
-4-
19. Denied. On the contrary, for the reasons set forth in
Defendants' other Answers to Plaintiff's Complaint and New Matter,
Ray Reed is not obligated to pay for the care of Dorothy Reed at
Shippensburg Health Care Center. As to the averments that care and
services provided constituted "necessaries", Defendants are without
knowledge or information sufficient to form a belief as to the
truthfulness of those averments and proof thereof is demanded.
20. Denied. On the contrary, the averments of Defendants'
other Answers to Plaintiff's Complaint and New Matter are
incorporated herein by reference thereto.
21. Denied. On the contrary, the averments of Defendants'
other Answers to Plaintiff's Complaint and New Matter are
incorporated herein by reference thereto.
WHEREFORE, Defendants request judgment be entered in favor of
the Defendants and against the Plaintiff.
COUNT II - QUANTUM MERUIT
22. No answer required.
23. Admitted.
24. Admitted in part. Denied in part. It is admitted that
Dorothy Reed has failed to pay for the cost of her care at
Shippensburg Health Care Center. The remaining averments are
denied. On the contrary, the averments of Defendants' other
Answers to the Complaint and New Matter are incorporated herein by
reference thereto.
-5-
25. Denied. On the contrary, the averments of Defendants'
other Answers to the Complaint and New Matter are incorporated
herein by reference thereto.
WHEREFORE, Defendants request judgment in favor of the
Defendants and against the Plaintiff.
~W~ATTER
26. Plaintiff has pleaded no facts which allege Defendants
are obligated in any manner to the Plaintiff, Shippensburg/South
Hampton Manor, LP. If any obligation is owed by the Defendants
(which is denied), it is to Shippensburg Health Care Center which
provided care for Mrs. Reed,
27. Dorothy Reed was a
nursing care facility after
as admitted above.
resident at York Hospital's skilled
being diagnosed as suffering from
Alzheimer's. At Mr. Reed's request, in order to transfer Mrs. Reed
closer to her home, the Social Worker at York Hospital arranged for
a transfer to Shippensburg Health. Mrs. Reed's care at York
Hospital was fully covered by her medical insurance.
28. Mrs. Reed agreed to be admitted and was only admitted to
Shippensburg Health Center on the condition precedent that the
total cost of her care would be paid by her medical insurance
carrier, Anthem Blue Cross/Blue Shield, as confirmed by Exhibit "C"
attached hereto, and not by Mr. Reed or i~er, personally, which
confirmation Shippensburg Health received and agreed to accept.
29. Defendant Ray Reed took Defendant
Shippensburg Health Care Center on May 28, 2003.
Dorothy Reed to
Due to
Mrs. Reed's medical condition, she was not capable of signing
documents at the time of her admission. Defendant Ray Reed signed
them on her behalf as her representative. He did not assume
personal responsibility for payment for her care.
30. Shippensburg Health Care Center assumed sole
responsibility for properly preparing and submitting claims for
payment for services and care provided to Mrs. Reed to Anthem Blue
Cross/Blue Shield.
31. Defendant Dorothy Reed was discharged from Shippensburg
Health Care Center to her home on July 2, 2003. At some unknown
time Shippensburg Health Care Center submitted its claim for
payment to Anthem Blue Cross/Blue Shield. By letter dated
October 16, 2003, Anthem Blue Cross/Blue Shield responded to
Shippensburg Health Care Center denying the claim on the basis that
the care provided was "psychiatric and behavioral" not "skilled
nursing care". Dorothy Reed was admitted to the Shippensburg
Health Care Center for skilled nursing care, although her medical
insurance policy does cover up to 45 days for mental health issues,
as well.
32. Attached hereto, made a part hereof, and marked
Exhibit "E" is a true and correct copy of the letter from Anthem
Blue Cross/Blue Shield to Shippensburg Health Care Center. First,
it is obvious from the response that the claim submitted for
payment was not properly made. Second, the fourth paragraph of
Exhibit "E" demonstrates that Shippensburg Health Care Center had
the means of rectifying the rejection by requesting reconsideration
of the decision.
33. It is believed and therefore averred that Shippensburg
Health Care Center did not request a reconsideration of the
decision nor submit correct information to Anthem Blue Cross/Blue
Shield. If Shippensburg Health Care Center had done so, it would
have received payment in full for its services provided, pursuant
to its agreements with Anthem Blue Cross/Blue Shield and Mrs. Reed.
34. After Mr. Reed received the Shippensburg Health's bill of
November 23, 2003, attached as Exhibit "B" to Plaintiff's
Complaint, he contacted Lear Corporation, which provides
Mrs. Reed's medical insurance coverage. Attached hereto, made a
part hereof and marked Exhibit "F" is a true and correct copy of
Lear Corporation's letter of December 16, 2003, confirming
Defendant Dorothy Reed's care at Shippensburg Health Center is
fully covered by her medical insurance.
35. Shippensburg Health Care Center is entitled to payment
through Dorothy Reed's medical insurance carrier, Anthem Blue
Cross/Blue Shield, for the entire cost of her care at the
Shippensburg Health Care Center from May 28, 2003 through July 1,
2003, in accordance with the agreement of the parties, as soon as
Shippensburg Health Care Center properly submits its claim for
payment to the medical insurance company. Under the circumstances,
neither Defendant has any obligation to Shippensburg Health Care
Center or Plaintiff.
36. The contract between Dorothy Reed, by her authorized
representative, Ray Reed, expressly provided that Shippensburg
Health Care Center would accept as full payment Mrs. Reed's medical
insurance coverage, which had been pre-approved prior to her
admission and that neither Defendant would be personally
responsible to Shippensburg Health for the cost of Mrs. Reed's
care.
37. Under the law of the Commonwealth of Pennsylvania and the
United States of America, based upon the facts and circumstances of
this case, Defendant Ray Reed, is not obligated in any manner for
any obligation which may be owed to Shippensburg Health Care Center
for the care of Dorothy Reed from May 28, 2003 to July 2, 2003.
WHEREFORE, Defendants request Your Honorable Court to enter
judgment in favor of the Defendants and against the Plaintiff.
Respectfully sub,mit ~e~,
35 East High Street, Suite 203
Carlisle, PA 17013
(717) 241-4311
Attorney for Defendants
-9-
VERIFICATION
Dorothy Reed and Ray Reed hereby verify that the facts set
forth in the foregoing Answer and New Matter are true and correct
to the best of their knowledge, information and beliDf, and
understand that false statements herein are made subject to the
penalties of 18 Pa. C.S. §4904 relating to unsworn falsifications.
DATE: January 23, 2004
-10-
SHIPPENSBURG HEALTH CARE CENTER
INSURANCE COVERAGE VERIFICATION
To verify the Medicare Claim Numbcr Contactl
Name of Resident: '~")O¢-O~¢hx-/
Social Security #:
Medicare//: C~
Contact Persoo:
/
Part A: Mcs No
Part ~ Ycs No
/
NO Cove/~- Explain:__ __
U cs/~e exactly ~s. it ~p. p~:rs ~n Social Security: (VERY IMPORTANT! H)
/I>~0TE: A copy of thc Medicare Card can be used as coverage ~crifica.tion.
" , E
SOCIAL SELURITY OFFIC
DateofBirth: l/- ~)Ci-
Datc Verified:
Additional Insurance Coverage Verification:
h~sumncc Compm~y Name: ~
Contact Person: Title:
Address:
Phone://
BencfitsAvailable: /20 Cl. Ot~!-~, / c4_C¢~(-rt_~ ~' IC:OC%c, ~,~MF
Facility Employco Vcri6'ing Information: ~ ~ ~( ~ ~ ~q~Datc Verified: ~-O~
1,"~22Cb[ , ~_C~ , have been iaformed of Medicare and secondary insurance coverage
pertainin~ to the period of stay at Shippensburg Health Care Center.
ignatu'rk of Res'ident or Authorized Representative Date
Anthem..'D.
Date.: 10/16/2003
Shippensburg Healtcare Center
121 Walnut Bottom Rd
Shippensburg, PA 17257
Re: Identification No: 191461736
Case No: 7030162730
Dear Dorothy A Reed
It's important to us that you receive all the benefits your health plan promised and that you understand how your
benefits work. In cases where coverage is not approved, we want you to understand why.
Your Anthem health care benefits require that we review your inpatient services to determine if the services are
medically necessary, covered under your plan and provided in the appropriate medical setting. We have
completed a review for your skilled nursing home admission of 05/28/2003 and we are sorry to inform you that we
are unable to provide coverage. Our review included all of the medical information we have on your case, along
with the Recovery Facility Guidelines / Milliman Care Guidelines 8th edition. Our review indicated that the care you
received was psychiatric and behavioral in nature and you did not receive skilled medical services such as
extensive wound care, aggressive therapies, or complicated IV therapies.
According to your health care coverage, services in a skilled nursing facility are covered when medically skilled
services are provided. Coverage is not provided for services that are custodial or can be managed in the home or
.in an outpatient setting such as your physician's office.
We are sorry that our decision was not a favorable one. If your physician would like to discuss this with me fudher,
he or she can call me at 1-800-242-7277. Your physician can also request a reconsideration of this decision. To
request a reconsideration, your physician or the hospital must call us and provide any additional information we
may not have. Your case will then be reviewed by another physician who did not participate with this decision and
a decision rendered within 10 working days after we receive the verbal request You also have a right to see, upon
request and at no charge, any rule, guideline, protocol, criterion or medical records that Anthem relied upon in
n,aking this coverage decision.
With Anthem coverage, you have the right to request an appeal of this decision. As part of this process, you are
entitled to be represented by an attorney or any person you may need to authorize to act on your behalf. To appeal
this coverage decision, please send to the address below a written explanation of why you feel the coverage
decision was incorrect. Unless your plan specifies otherwise, this information may also be provided to us over the
phone.
Send written appeals to:
Anthem Blue Cross Blue Shield
Attn: Corporate Appeals Department
P.O. Box 27401
Richmond, VA 23279
You must file your appeal within either 15 months of the date of service or 180 days of the date on this letter,
whichever is later. In either case, Anthem will resolve and respond in writing to all appeals within 60 calendar days.
If you are a member of an ERISA-regulated group health care plan, you may have the right to bring civil action
PC044
Anthem Blue Cross and Blue Shield is'the b-ade name of Anthem Health Plans of Virginia. Inc,
An independent licensee or the Blue Cross and Blue Shield Asso:iation,
® Registered marks Blue Cross and Blue Shield Association.
under bOZ (a} ot ERISA. Federal, state and local government programs, church plans, and individual policies are
not regulated under ERISA.
Thank you for the opportunity to review your request. Should you have any further questions, please contact
Klm Taylor RN, your case manager, at 1-800-242-7277. We are available lo assist you between the hours of 8:00
A.M. and 5:00 P.M., Monday through Friday. If you need to call after hours or on holidays, our answering service
wiII take a message and we'll call you back the next business day.
Sincerely,
Jay Schukman MD, Medical Director
Medical Management Program
cc: Shippensburg Healtcare Center
Dr B. Drew Wellmon
Patient Name:
Health Plan:
Facility:
Physician:
Non-covered Period:
Dorothy A Reed
Anthem Blue Cross and Blue Shield
Shippensburg Heaitcare Center
Dr B. Drew Wellmon
05/28/2003 - 07/01/2003
PC044
Anthem Blue Cross and Blue Shield is the Irade name of Anthem Health plans of Virginia. Inc.
An independent licensee of the Blue Cross and Blue Shield Association..
® Registered marks Blue Cross and Blue Shield Association.
O LEAR
CORPORATION
Interior Systems G~oup
50 Spring Road
Carlisle, PA 17013 USA
Phone [717] 249-1866
December 16, 2003
Phone: (717)-258-7440
Fax: (717)-258-7604
Mr. Ray Reed
1817A Heishman Gardens
Carlisle PA 17013
Re: Shippensburg Healthcare Center
Dear Ray,
I called Anthem and spoke with Leslie in the Customer Service Center on 12-15-03 concerning
the issue that coverage of Dorothy's stay at the above referenced facility was denied.
I relayed to Leslie that according to the Summary Plan Description that Dorothy has skilled
nursing coverage; as well as a 45 day limit for mental health issues. I further indicated that I,
myself, called Anthem and spoke with Trudy who advised that Dorothy was covered under a
skilled nursing facility, as long as it was a PPO. She agrees with me.
She indicated that apparently the problem lies with the manner in which the claim was submitted
and that the Healthcare Center needs to contact Anthem to determine exactly how this should be
submitted in order for coverage to take effect. Leslie also indicated that the letter the healthcare
center received from Jay Schukman denying coverage due to the fac~ that it was submitted as
skilled nursing, rather than a psychiatric stay.
Leslie advised that you should have the healthcare provider re-contact Anthem at the following
phone number: 1-800-242-7277.
Hopefully, this will resolve the issue.
Mana~n~i'" Nancy,,. Shellenbn~tgr~;ive and Benefit Services
SHIPPENSBURG/
SOUTH HAMPTON SLANOR, LP,
Plaintiff
vs.
DOROTHY REED and
RAY REED,
Defendants
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: CIVIL ACTION
:
: NO. 2003 - 8660 CIVIL TERM
:
: CIVIL ACTION - LAW
:
: JURY TRIAL DEMANDED
CERTIFICATE OF SERVICE
AND NOW, this 26th day of January, 2004, I, Dale F. Shughart,
Jr., Esquire, attorney for Dorothy and Ray Reed, Defendants, hereby
certify that I have served a copy of the Answer and New Matter by
mailing a copy of the same by United States mail, postage prepaid,
addressed as follows:
David A. Baric, Esquire
O'Brien, Baric & Scherer
17 West South Street
Carlisle, PA 17013 ~a~~
Dale F. L '
Attorney I.D. 1937[
35 East High Street, Suite 203
Carlisle, PA 17013
(717) 241-4311
Attorney for Defendants
SHIPPENSBURG/
SOUTH HAMPTON MANOR, LP
Plaintiff
DOROTHY REED and
RAY REED,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2003-6660 CIVIL TERM
CIVIL ACTION-LAW
REPLY TO NEW MATTER
AND NOW, comes Plaintiff, by and through its attorneys, O'BRIEN, BARIC &
SCHERER, and files the within Reply to New Matter and, in support thereof, sets forth the
following:
26. Denied. By way of further answer, Shippensburg/South Hampton Manor, L.P. is
the limited partnership which owns and operates the skilled care facility known as Shippensburg
Health Care Center.
27. After reasonable investigation, Plaintiff is without knowledge, information or
belief sufficient to form a belief as to the truth of these averments and they are, therefore, denied.
28. Denied. To the contrary, the Defendants agreed to be responsible for costs of care
which were not covered by a third party payor and at no time did the Defendants indicate that
complete insurance coverage was a condition precedent to admission of Dorothy Reed to the
facility.
29. Denied. After reasonable investigation, Plaintiff is without knowledge or
infom~ation sufficient to form a belief as to the troth of the averments regarding transportation of
Dorothy Reed to the facility or her ability to sign documents. The remaining averments are
denied. To the contrary, Ray Reed was noted as being the "Responsible Party". Moreover, a
husband is responsible for the costs of necessaries provided to his spouse.
30. Denied. To the contrary, the policy of insurance is held by Dorothy Reed.
31. Admitted in part and denied in part. Admitted only that Dorothy Reed was
discharged from the facility on July 2, 2003, that Plaintiff submitted a bill for costs of care to
Anthem Blue Cross/Blue Shield and that Anthem has failed and refused to pay the costs. The
remaining averments are denied as the Plaintiff is, after reasonable investigation, without
information or knowledge sufficient to form a belief as to their truth.
32. Denied. To the contrary, the letter is directed to Dorothy Reed and indicates that
she has the right of appeal of the decision. Further, there is no indication from the letter that
supports Defendants' bald assertions that a claim was "not properly made".
33. Admitted in part and denied in part. Admitted only that Plaintiff has not
requested a reconsideration of the decision made by the health care insurer of Defendant,
Dorothy Reed. Any implication that Plaintiff is required to make such a request is denied. The
remaining averments are denied. Moreover, Defendants' averments regarding payment by the
insurance company are pure speculation.
34. After reasonable investigation, Plaintiffis without knowledge or information
sufficient to form a belief as to the truth of these averments and they are, therefore, denied.
35. Admitted in part. It is admitted only that Plaintiff is entitled to payment from
either the insurer of Dorothy Reed and/or the Defendants. The remaining averments are denied.
To the contrary, the Defendants are directly obligated to Plaintiff to pay for the costs of care
provided.
36. Denied. To the contrary, the contract specifically and clearly obligated the
Defendants to pay for the costs of care.
37. Denied. To the contrary, Defendants are obligated to pay for the costs of care.
WHEREFORE, Plaintiff requests judgment in its favor and against Defendants as prayed
for in Plaintiff's complaim.
Respectfully submitted,
O'BRIEN, BARIC & SCHER~R
David A. Baric, Esquire
I.D. 44853
17 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/reed/newmatter, rep
VERIFICATION
I verify that the statements made in the foregoing Reply To New Matter are true and correct
to the best of my knowledge, information and belief. This verification is signed by David A. Baric,
Esquire, Attorney for Plaintiff and is based upon the statements provided by Plaintiff, as well as
documents reviewed by the undersigned as attorney for Plaintiff. This verification will be substituted
and ratified by a verification signed by the Plaintiff who is presently unavailable to sign said
verification. I undersigned that false statements herein are made subject to penalties of 18 Pa.C.S.
§4904, relating to unsworn falsifications to authorities.
Dated: a~//t~/~¢
David A. Baric, Esquire
CERTIFICATE OF SERVICE
I hereby certify that on February 10, 2004, I, David A. Baric, Esquire of O'Brien, Baric &
Scherer, did serve a copy of the Reply To New Matter, by first class U.S. mail, postage prepaid, to
the party listed below, as follows:
Dale F. Shughart, Jr., Esquire
35 East High Street, Suite 203
Carlisle, Pennsylvania 17013
David A. Baric, Esquire
SHIPPENSBURG/
SOUTHAMPTON MANOR, LP
Plaintiff
DOROTHY REED and
RAY REED,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2003-6660 CIVIL TERM
CIVIL ACTION-LAW
ORDER OF COURT
AND NOW, this ~t; day of ~~,2004,
foregoing Petition For Appointment Of Arbitrators, ~//d~
¢
arbitrators in the above-captioned action as prayed for.
in consideration of the
BY THE COURT,
SHIPPENSBURG/
SOUTHAMPTON MANOR, LP
Plaintiff
DOROTHY REED and
RAY REED,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2003-6660 CIVIL TERM
CIVIL ACTION-LAW
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, JUDGES OF SAID COURT:
David A. Baric, Esquire, counsel for the Plaintiff in the above-captioned action,
respectfully represems that:
1. The above-captioned action is at issue.
2. The claim of the Plaintiff in the action is $9,221.10.
The following attorneys are interested in the case as counsel or are otherwise disqualified
to sit as arbitrators: David A. Baric, Esquire and Dale F. Shughart, Jr., Esquire.
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3)
arbitrators to whom the case shall be submitted.
Respectfully submitted,
O'mE A aC %S RER
David A. B~ic, Esquire
I.D. ~ 44853
19 West South S~eet
C~lisle, Pe~sylv~ia 17013
(717) 249-6873
dab.dir/shcc/reed/ar bitr ation.pet
CERTIFICATE OF SERVICE
I hereby certify that on September g _, 2004, I, David A. Baric, Esquire of O'Brien,
Baric & Scherer, did serve a copy of the Petition For Appointment Of Arbitrators, by first class
U.S. mail, postage prepaid, to the party listed below, as follows:
Dale F. Shughart, Jr., Esquire
35East High Street, Suite 203 /]
Carlisle, Pennsylvania 17013
David A. Baric, Esquire
Plaintiff
D~endant
In The Court of Common Pleas of Cumberland
County, Pennsylvania No.
Civil Action - Law.
Oath
We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United
States and the Constitution of this Commonwealth and that we will discharge the duties of our office
Name (Chairman)
:awF~ p
Address [~
Signature
N~me
Law F/nn
Address
City, Zip
Signature
Ad,ess
ci~, zip
Award
We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the
following award: ..--(Note: If damages for delay ~e awarde, l;1, they shall be~para, tely s~.ted.)
/....nAIbitrat/~di/~ents. (Ins ert name if apphcable.)
Notice of Entry of Award
:ow, the 13~' dayof h~,.--->,-~, ,20~q ,at.;.:3 , /~.~., the above award ~v~s
entered upon the docket and notice thereof given by mail to the parties or their attorneys.
Arbitrators' compensation to be paid upon appeal: $ o,Qc~f3,,or-)
Prothonotary C Deputy
SHIPPENSBURG/
SOUTH HAMPTON MANOR, LP
Plaintiff
DOROTHY REED and
RAY REED,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2003-6660 CIVIL TERM
CIVIL ACTION-LAW
PRAECIPE TO SATISFY
TO THE PROTHONOTARY:
Please mark the judgmem entered in the above-captioned matter on December 13, 2004
as satisfied.
Respectfully submitted,
O'BRIEN, BARIC & SCHERER
, 7
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
dab.dir/shcc/reed/satisfy.pra
CERTIFICATE OF SERVIC. E
I hereby certify that on December 29, 2004, I, David A. Baric, Esquire of O'Brien, Baric
&Scherer, did serve a copy of the Praecipe To Satisfy, by first class U.S. mail, postage prepaid,
to the party listed below, as follows:
Dale F. Shughart, Jr., Esquire
35 East High Street, Suite 203
Carlisle, Pennsylvania 17013
David A. Baric, Esquire