HomeMy WebLinkAbout04-1473RICHARD F. MAFFETT, JR., ESQUIRE
ID #3§539
2201 North Second Street
Harrisburg, PA 17110
717-233-4160
Attorney for Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
JAMES L. MILLER, Parent and
Natural Guardian of SAMANTHA JO
MILLER, a Minor, Plalntlffs
296 Old Stonahouse Road
Carlisle, PA 17013
v
JORDAN L. BRANDT, Defendant
161 Valley Drive
Carlisle, PA 17013
NO.
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
PRAECIPE FOR WRIT OF SUMMONS
TO THE PROTHONOTARY OF SAID COURT:
Please issue Writ of Summons in the above-captioned action.
Writ of Summons
Date:
shall be
issued and forwarded to Sheriff.
R . Maffe~t', J~., Esq.
WRIT OF SUMMONS
TO THE ABOVE NAMED DEFENDANT:
YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFFS HAVE
CO~ENCED AN ACTION AGAINST YOU.
P~otho~otary
Deputy
SHERIFF'S RETURN - REGULAR
CASE NO: 2004-01473 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
MILLER JkMES L ET AL
VS
BR3kNDT JORDAN L
CPL. MICHAEL BARRICK , Sheriff or Deputy Sheriff of
Cumberland County, Pennsylvania, who being duly sworn according to law,
says, the within WRIT OF SUMMONS was served upon
BRANDT JORDAN L
DEFENDANT , at 2020:00 HOURS,
at 161 VALLEY DRIVE
CARLISLE, PA 17013
DAVID BP~ANDT, FATHER
a true and attested copy of WRIT OF SUMMONS
on the 8th day of April
by handing to
the
, 2004
together with
and at the same time directing His 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
~W3~ A.D.
Prothonotary / ~
So Answers:
R. Thomas Kline
04/12/2004
RICFIARD MAFFETT JR
RICHARD F. MAFFETT, JR., ESQUIRE
ID #35§39
2201 North Second Street
Harrisburg, PA 17110
717-233-4160
Attorneys for Petitioner
JAMES L. MILLER, Parent and
Natural Guardi&n of SAMANTHA
JO MILLER, a minor,
Petitioner
v
JORDAN L. BRANDT, ResDon~ent
IN THE COURT OF COMMON PLEAS
CUMBERLAND. COUNTY, PENNSYLVANIA
NO. 04-1473
CIVIL ACTION - LAW
PETITION FOR APPROVAL OF
COMPROMISE SETTLEMENT INVOLVING
A MINOR
PETITION FOR APPROVAL OF MINOR'S SETTLEMENT
AND NOW, this 22nd day of April, 2004, comes JAMES L.
MILLER, Parent and Natural Guardian of SA~L~NTHA JO MILLER,
their attorney, Richard F. Maffett, Jr., Esquire,
this Petition For Approval of Minor's Settlement,
thereof,
by
and submits
and in support
avers the following:
COUNT I:
JORDAN L. BRANDT AND ALLSTATE INS~ANCE COMPANY
1. Petitioner, JAMES L. MILLER, is
guardian of SAMANTHA JO MILLER, a minor,
August 1, 1986.
2. The minor, SAMANTHA JO MILLER, resides with her parents,
Petitioner, JAMES L. MILLER, and STEPHANIE MILLER at 296 Old
Stonehouse Road, Carlisle, Cumberland County, Pennsylvania, who
have sole custody of said minor.
the parent and natural
age seventeen (17), born
3. Respondent, JORDAN L. BRANDT, is an adult individual,
age eighteen (18), having a date of birth of February 26, 1986,
who resides with her parents at 161 Valley Drive, Carlisle,
Cumberland County, PA.
4. The above-captioned action involves a claim for damages
as a result of injuries suffered by the minor, SAMANTHA JO
MILLER, when she was involved in an automobile accident.
5. The aforesaid automobile accident occurred on
January 26, 2003, at about 4:20 p.m. on Interstate Route 81, in
Middlesex Township, Cumberland County, PA.
6. The minor, SAMANTHA JO MILLER, was a passenger in a
vehicle driven by Respondent JORDAN L. BRANDT, which was headed
southbound on Interstate Route 81 in the passing lane.
7. At the aforesaid time and place, Respondent JORDAN L.
BRkNDT, lost control of her vehicle, which left the roadway,
traveled across the median; and, entered the northbound lanes of
Interstate Route 81 headed southeast, where the rear of
Respondent BRAIqDT'S auto collided with the left side of a fully
loaded tractor trailer. (See Police Report attached as
Exhibit A.)
8. All of the injuries and damages suffered by the minor,
SAMANTHA JO MILLER, are the direct result of the negligence of
Respondent JORDAN L. BRANDT in: driving her automobile too fast
2
for conditions; and,
her vehicle.
9. The minor, SAMANTHA JO MILLER, was ejected from the
Respondent BRANDT'S vehicle and suffered multiple serious
injuries. (See Discharge Summary attached as Exhibit B.)
10. The minor, SAMANTHA JO MILLER was an inpatient at the
Milton S. Hershey Medical Center for sixteen (16) days from
January 26, 2003 through February 10, 2003. (See Exhibit B
attached.)
11. On January 26, 2003, surgery in the nature of a
splenectomy and laporotomy was performed; and, SAMANTHA JO
MILLER'S dislocated right hip was also put back into place.
(See Exhibit B attached.)
12. The minor, SAMANTHA JO MILLER, suffered the following
injuries:
a. closed head injury;
b. left frontal cephalohematoma;
c. multiple lacerations, bruises & abrasions of the
face, right shoulder, right hand & left knee;
d. C4 facet fracture;
e. fractured right clavical;
f. comminuted fracture of the riglht scapula;
g. bilateral pulmonary contusions;
h. bilateral hemothorax;
I. bilateral pneumothorax;
failing to maintain adequate control over
j. liver lacerations;
k. splenic lacerations;
1. retroperitoneal hematoma;
m. multiple rib fractures, including the posterior 10tn
and 11th ribs;
no compression fractures at T6,T9,T10,Tll, and T12;
o. burst fractures at T10,T12, and L1;
p. paraspinal hematoma;
q. transverse process fracture of the L5 vertebrae on
the right;
r. complex bilateral sacral fractures involving both SI
joints and the left sacrum;
s. complex comminuted right superior pubic rami
fracture;
t. comminuted right pelvic acetabular fracture; and,
u. fracture of the right femoral head.
(See Exhibit B attached.)
13. On February 5, 2003, the minor, SAMANTHA JO MILLER was
placed in a fiberglass full body cast in treatment of her spinal
fractures which she remained in for seven (7) weeks, until
March 19, 2003. (See Exhibit B attached.)
14. After her discharge from the hospital, the minor,
SAMANTHA JO MILLER, has continued to receive outpatient treatment
through the Milton S. Hershey Medical Center.
15. The minor, SAMANTHA JO MILLER bears a sixteen (16) inch
scar down the middle of her abdomen; and, must take penicillin
4
daily for the rest of her life because of the loss of her spleen.
She is more susceptible to infection and cannot play contact
sports.
16. The minor, SAMANTHA JO MILLER also has a two (2) inch
scar above her left eyebrow; and, a five (5) inch scar on her
right leg.
17. The minor, SAMANTHA JO MILLER has made an excellent
recovery, although she continues to have lower back pain. (See
treatment notes of June 4, 2004 and July 24, 2003, attached as
Exhibit C.)
18. The minor, SAMANTHA JO MILLER, has incurred medical
bills for treatment of her injuries caused by the aforesaid auto
accident in excess of $107,894.16.
19. Petitioner had first party medical bill coverage with
Erie Insurance Group in the amount of $10,000.00, which has been
exhausted. (See Exhibit D attached.)
20. Most of the remainder of the medical bills of the minor,
SAMANTHA JO MILLER, have been paid by health insurance,
Keystone Health Plan Central, which Petitioner, JAMES L. MILLER,
makes partial payment for through his employment.
21. By letter dated April 5, 2003, Keystone Health Plan
Central was given notice that the injuries of the minor, SAMANTHA
JO MILLER, had been caused by an automobile accident and that
first party automobile insurance benefits had been exhausted.
(See Exhibit E attached.)
22. Petitioner has not received any notice of a subrogation
claim from Keystone Health Plan Central for reimbursement of any
health insurance benefits paid on behalf of the minor, SAMANTHA
JO MILLER.
23. Undersigned counsel has reviewed the Subscriber Agreement
of Keystone Health Plan Central; and, believes, and therefore
avers, that there is no enforceable subrog'ation right under the
Motor Vehicle Financial Responsibility Law. (See Subscriber
Agreement attached as Exhibit F.)
24. At the time of the aforesaid accident, the minor,
SAMANTHA JO MILLER, was in the eleventh (llth) grade at
Cumberland Valley High School; and, as a result of her injuries,
was unable to return to school for the balance of the 2002-2003
received home-bound instruction. (See Exhibit G
school year, but
attached.)
25. Because
the minor, SA~4ANTHA JO MILLER was a high school
student at the time of her injuries, she was not employed and
suffered no wage loss.
26. Respondent, JORDAN L. BRANDT, was covered by two (2)
policies of automobile insurance with Allstate Insurance Company
as follows:
6
Pol£c~ No.
1554556561 B19
1554555480 B19
Patricia Coia, owner of auto
Rebecca Brandt, Respondent's
mother
Policy Limit
$15,000-30,000
$100,000-300,000
$109,125.00:
a. $10,000.00 paid on 08/01/06 (age 20);
b. $10,000.00 paid on 08/01/08 (age 22);
c. $15,000.00 paid on 08/01/10 (age 24);
d. $20,000.00 paid on 08/01/12 (age 26);
e. $24,125.00 paid on 08/01/14 (age 28);
f. $30,000.00 paid on 08/01/16 (age 30).
(See Exhibit H Attached.)
27. Allstate Insurance Company has agreed, subject to the
approval of Your Honorable Court, to pay their policy limits in
settlement of this claim, which total $115,000. (See Exhibit I
attached.)
28. In order to provide maximum recovery and security for
his minor daughter, SAMAI~THA JO MILLER, Petitioner, JAMES L.
MILLER, desires to enter into a structured settlement with
Allstate Insurance Company, whereby $76,667.00 of the settlement
proceeds would be used to purchase an Annuity Contract from
Allstate Life Insurance Company. (See Exhibit J attached.)
29. As of March 25, 2004, the aforesaid Annuity Contract,
would guarantee, the following tax-free payments to SAMANTHA JO
MILLER on the following schedule, for a total payout of
(See Exhibit J attached.)
30. Petitioner believes, and therefore avers, that there is
no other liability insurance coverage available to Respondent
BRANDT, nor does she own any significant unencumbered
JORDAN L.
assets.
31.
Although the proposed settlement is not adequate to
compensate the minor, SAMANTHA JO MILLER, for all of her
injuries and damages caused by the aforesaid accident, it is
unlikely that additional assets can be obtained from the
tortfeasor, Respondent JORDAN L. BRANDT, the only negligent
party, and the expense and delay of further litigation are not in
the best interests of the minor, SAMANTHA JO MILLER.
32. Petitioner JAMES L. MILLER, and undersigned counsel,
Richard F. Maffett, Jr., Esquire, believe and therefore aver that
the proposed settlement is reasonable and in the best interests
of the minor, SAMANTHA JO MILLER.
33. Petitioner also has underinsured motorist coverage for
the injuries and damages suffered by his minor daughter, SAMANTHA
JO MILLER, through his automobile insurance policy with Erie
Insurance Group in the amount of $200,000. (See Exhibit K
attached.)
34. Erie Insurance Group has also agreed to pay to the
minor, SAMANTHA JO MILLER, the limits of the aforesaid
underinsured motorist coverage, in the amount of $200,000,
pursuant to a structured settlement, which is the subject of
Count 2 herein. (See Exhibit L attached.)
35. Petitioner, JAMES L. MILLER is only aware of unpaid
medical bills for treatment of the injuries of the minor,
SAMANTHA JO MILLER, in the amount of $9,7213.26, which he proposes
to pay out of the settlement funds pursuant to the aforesaid
underinsured motorist coverage with Erie /insurance Group. (See
Count II herein.)
36. STEPHANIE L. MILLER, mother of the minor, SAMANTHA JO
MILLER, also agrees to the aforesaid settlement, believes it to
be in the best interests of her daughter, and desires that the
proposed settlement be accepted and approved. (See the Affidavit
of STEPHANIE L. MILLER attached as Exhibit M.)
37. Should the Court deem it necessary to schedule a hearing
to approve the settlement proposed herein, the minor, SAMANTHA JO
MILLER, and her parents, Petitioner, JAMES L. MILLER, and
STEPHANIE L. MILLER, are available to testify.
38. Undersigned counsel, Richard F. Maffett, Jr., Esquire,
has an attorneys fee agreement with Petitioner in this matter in
the amount of twenty-five (25%) percent of the amount recovered,
resulting in attorneys fees on the recovery from Respondent
JORDAN L. BRANDT, and Allstate Insurance Company, in the amount
of $28,750.00, subject to the approval of Your Honorable Court.
(See Exhibit N attached.)
9
39. Petitioner's attorney, Richard F. Maffett, Jr., Esquire,
has incurred the sum of $266.74 for out-of-pocket expenses in
prosecuting this claim; however, Petitioner proposes to make
reimbursement of these litigation expenses out of the proceeds of
the underinsured motorist settlement with Erie Insurance Group.
(See Exhibit 0 attached.)
W~ER~FOR~, Petitioner JAMES L. MILLER, Parent and Natural
Guardian of SAMANTHA JO MILLER, a minor, respectfully requests
that Your Honorable Court enter an order approving the foregoing
compromise settlement, directing distribution of the proceeds
thereof as set forth above, and authorizing Petitioner, upon
payment of the aforesaid sums to discontinue the action brought
to the above term and number, and to execute a good and
sufficient release to Respondent, JORDAN L. BRANDT, and Allstate
Insurance Company, of any and all claims by SAMANTHA JO MILLER, a
minor, and JAMES L. MILLER, as Parent and Natural Guardian of the
minor, and of all other persons, firms, or corporations arising
from or as a result of the incident referred to above.
COUNT II: ERIE INSURANCE GROUP
40. Petitioner incorporates by reference the averments of
Paragraphs 1 through 39 above as fully as though set forth at
length herein.
10
41. Petitioner's underinsured motorist coverage through his
automobile insurance policy with Erie Insurance Group is in the
aggregate amount of $200,000.00. (See Exhibit K attached.)
42. Erie Insurance Group has agreed to pay to Petitioner on
behalf of the minor, SAMANTHA JO MILLER, the limits of their
underinsured motorist coverage, in the amount of $200,000.00.
(See Exhibit L attached.)
43. The only unpaid medical bills of which Petitioner,
JAMES L. MILLER, is aware total $9,733.26, payment of which will
be made out the settlement funds from Erie Insurance Group,
subject to approval from Your Honorable Court.
44. In order to provide maximum recovery and security for
his minor daughter, SAMANTHA JO MILLER, Petitioner JAMES L.
MILLER, desires to accept the majority of the aforesaid
underinsured motorist settlement funds by way of a structured
settlement with Erie Insurance Group, whereby $130,912.00 of the
settlement proceeds would be used to purchase an Annuity
Contract from Erie Life Insurance Company.
45. As of March 18, 2004, the aforesaid Annuity Contract
would guarantee the following tax free payments to SAMANTHA JO
MILLER on the following schedule, for a total payout of
$182,500.00:
a.
b.
$10,500.00 paid on 08/01/06 (age 20);
$10,500.00 paid on 08/01/08 (age 22);
c. $10,500.00 paid on 08/01/10 (age 24);
d. $10,500.00 paid on 08/01/12 ([age 26);
e. $10,500.00 paid on 08/01/14 ([age 28);
f. $130,000.00 paid on 08/01/16 (age 30).
(See Exhibit P attached.)
46. Petitioner, JAMES L.
believe, and therefore aver,
MILLER, and undersigned counsel
that other than the sums listed
herein, there is no other insurance coverage applicable to the
minor, SAMANTHA JO MILLER, nor are there any other collateral
sources of recovery from which she would be likely to obtain
reimbursement for her injuries and damages.
47. Although the settlement with Erie Insurance Group
proposed herein is still insufficient to fully compensate the
minor, SAMANTHA JO MILLER, for all of her injuries and damages,
for all of the reasons set forth herein, Petitioner, JAMES L.
MILLER, and undersigned counsel believe that this settlement is
in the best interests of the minor, SAMANTHA JO MILLER.
48. STEPHANIE L. MILLER, mother of the minor, SAMANTHA JO
MILLER, also agrees to the aforesaid settlement with Erie
Insurance Group, believes it to be in the best interests of her
daughter, and desires that the proposed settlement be accepted
and approved. (See the Affidavit of STEPHANIE L. MILLER attached
as Exhibit M.)
12
49. Undersigned counsel, Richard F. Maffett, Jr., Esquire,
has an attorneys fee agreement with Petitioner in this matter in
the amount of twenty-five (25%) percent of the amount recovered
from Erie Insurance Group, resulting in attorneys fees of
$50,000.00, subject to the approval of Your Honorable Court.
(See Exhibit N attached.)
50. Petitioner, JAMES L. MILLER, has agreed, subject to
approval from Your Honorable Court, to reimburse Richard F.
Maffett, Jr., Esquire, the sum of $266.74 for out-of-pocket
expenses in prosecuting this claim. (See Exhibit 0 attached.)
W~I~R~FOR~, Petitioner, JAMES L. MILLER, Parent and Natural
Guardian of SAMANTHA JO MILLER, a minor, respectfully requests
that Your Honorable Court enter an order approving the foregoing
compromise settlement with Erie Insurance Company, directing
distribution of the proceeds thereof as set forth above, and
authorizing Petitioner, upon payment of the aforesaid sums to
execute a good and sufficient release to Erie Insurance Company,
of all claims by SAMANTHA JO MILLER, a minor, and JAMES L.
MILLER, as parent and natural guardian of the minor, and of all
other persons, firms, or corporations arising from or as a result
of the incident referred to above.
Respectfully submitted,
Attorney For Petitioner
· Number
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PENNDOT COPY
EXHIBIT "A"
· --.,a " POLICE CRASH REPORTING FORM
AA 4~ ~ ~ 00109'7
P0507258
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COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA454 1
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P0507258
Person Type:
A ~:o,,,,,,D
B F =Female
U =Unknown
Injury Seve~t~:
C {)=Not In urea 11 =In Other E~,d
Patsen~ Oe ~e~ Area
2=Ma~ Injury
3=M~e~ate (Ba~ Of Pickup, E~)
Inju~ 13=Traillng Un~
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9=Unknown 15=8us Pas~ge~
98=Othet
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Seat Position:
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Motorcycle
05=Seco~ Row. Midge ~on
06=S~ond Row- Right S~e
07=Third R~ Or Greater
Le~ Side
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10=Alt Bi(
11=Air
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POLICE CRASH REPORTING FORM (~ ~w i~
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PENNDOT COPY
COMMONWEALTH OF PENNSYLVANIA
POLICE CRA.SH REI~). RTING FORM
Order
4
Sequential
Order
Umt No Harm Event
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18=Tliilll'Ovef~0idid
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PENNDOT COPY
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AA 458 ~ 00110,3
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POLICE CRASH REPORTING FORM
AA458 1
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P0507344
Place emergency transport, witness, and other information here, It is not required to restate information from the fo~m. i
Addr~s:
PENNDOT COPY
AA45C 1
Unit Number
Carrier I'~a me
POLICE CRASH REPORTING FORM
001106
COMMONWEALTH OF PENNSYLVANIA
Page:
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ENN~T COPY
Surg D/C Summary MILLER, SAMANTHA J - 1265102
* Final Report *
D'r S CI-I~R~E S ~,ARY
PATIENT NAME= MILLER, SAMANTHAJ
PATIENT NUMBER: 0365450
LOCATIONs 7254
SEX: F
PRIMARY CARE PHYSICIAN: Denise F. Hart,
DATE ADMITTED: 01/26/2003
DATE DISCIiARGED: 02/10/2003
DATE OF BIRTH: 08/01/1986
M.D.
ADMISSION DIAGNOSIS: Multiple trauma.
PRINCIPAL DIAGNOSIS:
1. Bilateral pulmonary contusions.
2. Bilateral hemothorax.
3. Bilateral pneumothorax.
4. Liver lacerations.
5. Splenic laceration.
6. Pubic rami fracture.
7. Acetabular fracture.
8. Multiple lacerations and abrasions.
9. L1 and T12 vertebral fractures.
10. Closed head injury.
OPERATIONS OR PROCEDURES:
1. On January 26, 2003, exploratory laparotomy, splenectomy, and repair of
multiple lacerations.
2. On February 5, 2003, hyperextension casting of the thoracolumbar spine.
BRIEF COURSE: The patient is a 16-year-old white female who was brought into
Hershey Medical Center at a level i trauma after a rollover motor vehicle accident
with ejection. The patient was an unrestrained passenger in the car. She was
found to have multiple injuries including bilateral pul~Dnary contusions, bilateral
hemothoraces, bilateral pneumothoraces requiring chest tube insertions, liver and
splenic lacerations, multiple vertebral body fractures, ]pubic rami fracture,
acetabular fracture, multiple other lacerations, and a closed head injury. Both in
the emergency room and in the pediatric ICU where the pa'=ient was admitted status
post exploratory laparotomy and a splenectomy, the patient had profound hypotension
and severe pulmonary failure, and ARDS requiring incremental increase in her
respiratory support. Initially, the patient had approximately 700 cc of blood from
both of her chest tubes and over 200 cc of blood mixed with pulmonary edema from
her endotracheal tube with saturations varying between 8,9 and 92% despite changes
in her ventilatory parameters. The patient received continuous vigorous fluid
resuscitation due to ongoing losses prior to going to the operating room and
Pdnted by: Shiner, Crystal L Page 1 of 3
Pdnted on: 4/16/2003 2:00 PM (Continued)
EXHIBIT "B"
Surg D/C Summary MILLER, SAMANTHA J - 1265102
~hnderwent a tran~esoph~geal echocardiogram to look for an aortic injury. .The TEE
showed an unrefilled heart despite aggressive volume resuscitation. The patient is
also noted to have a mitral valve prolapse of a mild degree, but a qualitatively
normal cardiac function. The patient's blood pressure was stabilized on dopamine
drip. The patient received number of blood products as well as IV fluid boluses
receiving a total of 8 units of packed red cells, 6 %lnits of fresh frozen plasma, 6
units of platelets, and more plasma, platelets, packed red cells, and
cryoprecipitate in the operating room. In the operating room, she was found to
have an intraabdominal hemorrhage from her spleen laceration. Her liver laceration
was contained with signs of active bleeding and multiple retroperitoheal and
mesenteric hematomas. The patient was found to have intact diaphragm and bladder.
No other signs of active bleeding, status post her splenectomy where she was taken
to the PICU status post operation. The patient was seen by orthopedics after her
resuscitation for her clavicular, scapular, acetabular, and vertebral body
fractures without significant cord compromise and as noted all fractures are likely
be treated nonoperatively. The patient was placed on strict Tinel precautions.
Upon further review of the patient's x-rays and CT scans, a C4 fracture was noted.
The patient remained in an Aspen collar with good fit. The patient remains
intubated; however, awake, alert, and following commands. She was extubated on
postoperative day #5 and bilateral chest tubes were removed on postoperative day
#4. The patient continued to do well and extubated with minimal requirements for
additional oxygenation. The patient had some intermittent agitation. She was
started on TPN for nutrition and had a couple of episodes of fevers. The patient
continued to do well and was transferred from the PICU to the regular pediatrics
floor progressing in physical and occupational therapy. The patient had some
difficulties with pain control, but was comfortable when switched to OxyContin and
OxyIR. The patient had a body cast placed by orthopedics on postoperative day #14.
At this time, the patient was tolerating a regular diet, was having normal bowel
and bladder motions, was afebrile with stable vital signs, and walking well with
physical therapy and occupational therapy. The patient was discharged to home on
postoperative day #15.
DISCHARGE MEDICATIONS:
2.
3.
4.
5.
6.
Penicillin 500 mg p.o.q.d.
OxyContin 10 mg one p.o.b.i.d.
OxyIR 5 mg one p.o.q.4-6h, p.r.n.
Ambien 5 mg p.o.q.h.s.
Colace while on 0xyContin and OxyIR.
The patient may resume her usual home medications.
DISCHARGE ORDERS/INSTRUCTIONS:
1. Diet regular as tolerated.
2. Activity as tolerated per physical therapy teaching and sling to right upper
extremity for comfort.
3. The patient is to follow the orthopedic and status post concussion injury
worksheet.
4. They are advised to call the pediatric surgery office for the pediatric
surgery resident on call at 717-531-8521 with any questions or concerns. 5.
Comfort Care will be assisting the patient with her home medical needs.
Pdnted by: Shiner, Crystal L Page 2 of 3
Printed on: 4/16/2003 2:00 PM (Continued)
PENNSTKFE
W~Mi!,ton S.~¢rs,hgy Medical
~,..Oll~ge Ol meaic~ne
Center
Health Information Services
HU24
P.O. Box 850
Hershey, PA 17033-0850
An Equal Opportunity University
'Surg D/C Summary
MILLER, SAMANTHA J - 1265102
FOLLOW-UP APPOIATTMENTS:
1. With Dr. Segal in orthopedics on February 20, 2003.
2. Pediatric surgery clinic on March 5, 2003.
#000933
DICTATING MD:
Kimberli S. Cox, MD
ATTENDING MD:
Robert E. Cilley, MD
KSC/dts D: 02/27/2003
c: WP Clerk
DENISE F. F~RR, M.D.
1830 GOOD HOPE ROAD
ENOLA, PA 17025
T: 02/28/2003 18:25
Pdnted by:
Printed on:
Shiner, Crystal L
4/16/2003 2:00 PM
Page 3 of 3
(End of Report)
PENNSTATE
Milton S. Hershey Medical Center
College of Medicine
HU24
P.O. Box 850
Hershey, PA 17033-0850
An Equal Opportunity University
PEDIATP C S RGEONS
OF CENTRAL PENNSYLVANIA
Robert E, Cllley, M.D.
Kerr~ M. Fagalm~, M.D.
Andr~l H. ~e~er, M.D.
PENNSTATE
Denise Hair, M.D.
1830 Good Hope Road
Enola, PA 17025
Jtmc4,2003
RE: MILLER, S amantha
MSHMC# 1265102
Dear Dr. Hart:
we saw Samantha in our clinic ht follow t~p for her multi-tram accident earlier
this year. She is now about five months out from h~r injuries. As you recall, she suffered
multiple vertebral fractures as well as her hip fracture. She remains on penicillin for
prophylaxis. She still has some back pain and until today was still taldng some Vicodin.
About six weeks ago, she started to wean off ff~e back brace and has now perforiued physical
therapy over the last three weeks. She is overall doing fairly well and her pain CUmlAaint
is the Iow back pal~ She continues to follow with Dr. Scgal for the multiple fractures.
On physical exam she is fairly pleasant and i[n no acute distress. Her head and neck
exam is unremarkable. The previous scar over the upper fight back has healed nicely. Her
lower back is straight and there js no significant tenderness noted. Her abdomen shows a
well-healed midline scar. The abdomen is flat.
Impression: Samantha is doing reasonably 'well after her severe injuries. She is
currently still home-schooled. I talked to her and mentioned that the lower back pain is
something she will most likely have for the foreseeable future. I strongly advised her not
to continue the Vicodin ff at all possl%le as it is a habit-forming drug. I recotm~ended trying
Tylenol and Motrin as a combination to see whether she can get relief for her back pain. I
highly encouraged her to continue with physical therapy to gain some muscular strength
which will support her lower back. She is also schednied to follow up with Dr. Segal in
about four to six weeks. At this point, further follow up with us is not necessary. We will
be available for her and the fa/ally in case they need l~-ther general trauma assistance.
Ohce again, thank you for allowing us to participate in Samantha's care.-
~~Mci~, M.D.
AHM/asap
CC:
Lee Segal, M.D.
Hershey Medical Center Pediatric
Hershey, PA 17033
Orthopedics
EXHIBIT "C"
Specializing in the Surgical Care of Infants, Children a nd Adolescents
An Equal Opportunity University
Ortho Outpt N'ote MILLFR, SAMANTH J - 1265102
* Final Report *
PEDIATRIC ORTHOPAEDIC CLINIC
PATIENT NAME= MILLER, SAMANTHA J
PATIENT NUMBER= 1265102
SEX= F
DATE OF SERVICE= 07/24/2003
DATE OF BIRTH: 08/01/1986
DATE OF BIRTH: 08/01/1986
HISTORY: The patient is a 17-year-old female who is 6 months status post
multiple injuries from motor vehicle accident. She sustained right clavicle
fracture and glenoid fracture, C4 spine fracture, right anterior hip
dislocation, LC3 pelvic ring fracture as well as ~ltiple thoracolumbar spine
fractures at the T6, T10, Tll, and L1 levels. She has had a posttraumatic
kyphotic deformity. She did receive physical therapy, which she has
completed. She has been out of brace. Denies any neck pain. Denies any
specific right shoulder pain. She has some difficulty carrying a book bag on
the right shoulder. Hip is okay. She is unable to sit for prolong periods
of time and requires frequent stretching and also feels like her back needs
to be stretched out.
PHYSICAL EXAMINATION: On exam, she has excellent range of motion of the
cervical spine and full range of motion of the right shoulder except for
external rotation. There is a moderate posttraumatic kyphotic clinical
deformity. No pain with palpation of thoracolumbar spine. No pain with
range of motion of the right hip.
RADIOGRAPHS: Repeat films today of the thoracolum~ar junction reveal no
progression of her kyphosis, which measures 25 deg'rees from T9-Tll. It had
measured 26 degrees at last visit.
RECOMMENDATIONS: Return to clinic in 6 months. Additional physical therapy
for hyperextension exercises, strengthening, and home PT program were
prescribed. Return to clinic in 6 months to reevaluate at that time.
Printed by: Shiner, Crystal L Page 1 of 2
Printed on: 9/26/2003 3:40 PM (Continued)
PENNSTATE
~ Milton S. Hershey Medical Center
College of Medicine Hea:th Information Services
HU24
P.O. Box 850
Hershey, PA 17033-0850
An Equal Opportunity University
Ortho Outpt N'ote MILLFR, SAMANTH/~ J - 1265102
DICTATING MD:
ATTEA~DING MD:
Lee S. Segal, MD
Associate Professor, Orthopaedics
& Rehabilitation & Pediatrics
LSS/cbt D: 07/24/2003
DENISE HARR, MD*
1830 GOOD HOPE ROAD
ENOLA, PA 17025
T: 07/26/2003 18:25
Printed by: Shiner, Crystal L Page 2 of 2
Printed on: 9/26/2003 3:40 PM (End of Report)
PENNSTATE
~ Milton S. Hershey Medical Center
College of Medicine Health Information Services
HU24
P.O. Box 850
Hershey, PA 17033-0850
An Equal Opportunity University
KERRY J. RITCHEY, CPCU, AIC
Claims Manager
ERIE INSURANCE GROUP
Branch Office · 4901 Louise Dr. · Rossmoyne Business Center -'P.O. Box 2013 - Mechaniosburg, PA 17055-0710
(717) 795-8200 · Toll Free 1-800-382-1304 · Fax (717) 795-2315 · vcww.erieinsurance.com
March 25, 2003
Richard F. Maffett, Jr.
2201 North Second Street
Harrisburg, PA 17110
Erie Claim: 010170661624
Erie Insured: James L. Miller &
Stephanie L. Miller
Date of Loss: 1/26/03
Your Client: Samantha Miller
Dear Mr. Maffett:
I am in receipt of the letter of representation from your office dated March 24, 2003 and
acknowledge same.
Samantha Miller exhausted her First Party Benefits limit of $10,000.00 on
March 5, 2003. Enclosed is a copy of her payout sheet.
Should you have any questions, please feel free to contact me.
$incerety,
Lisa Maldonado
Medical Mgmt Speciahst
717-79:[-2229
EXHIBIT "D"
RECEIVED HAR 2 21)I)3
The ERIE Is Above All In sERvIcE~ · Since 1925
~03/25/2003
13:46
Claims Management System
Medical Management Print
Medical Payments
Req:
CSPP060B
'Page: 1
MALDONADO ,L
Claim: 010170661624
Ins: JAMES L MILLER &
Claimant: 002 SAMANTHA MILLER
Limit: 10000.00 Paid:
10000.00
CK
F145193
F145194
F145195
F145197
F145200
F145202
F145203
F145205
F145207
F145208
F145211
F145212
F145213
F145214
F145217
Amount
76 00
94 00
96 00
295 00
310 00
327 00
354 00
444 00
804 00
1097.00
440.00
978.00
1162.50
1252.50
2270.00
Payee
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
MILTON S HERSHEY MEDICAL CENTER
Service Date
20030205
20030129
20030130
20030126
20030126
20030126
20030128
20030127
20030201
20030126
20030126
20030126
20030126
20030126
20030126
to 20030205
to 20030130
to 20030131
to 20030127
to 20030201
to 20030126
to 20030128
to 20030129
to 20030205
to 20030126
to 20030126
to 20030126
to 20030126
to 20030126
to 20030126
April 5, 2003
Keystone Health Plan Central
P.O. Box 898812
Camp Hill, PA 17001-9927
Re: Member: Samantha Jo Miller
KHP Central ID# 168-48412703
Date of Accident: 01/26/03
Dear Sir or Madam:
I am the attorney for Samantha Jo Miller, and her parents, James E~
Stephanie Miller, regarding the automobile accident of January 26, 2003.
Enclosed is the authorization for release ot: information which has
been completed and signed by Mr. Miller. Also enclosed is the
February 28, 2003 request for information regarding exhaustion of
automobile insurance benefits, which has been completed and signed by
Mr. Miller. A copy of Erie Insurance Compan~/s letter of March 5, 2003
regarding exhaustion of benefits is enclosed.
With best regards,
RFM/cs
Enclosure
· cc: James E~ Stephanie Miller (w/enc)
Richard F. Maffett, Jr.
EXHIBIT "E"
P.O, Box 898~12
Camp Hill, PA 17089-8812
www,khpc.com
Dear Member:
In order for us to properly determine eligibility benefits under your contract, please
sign and date the form below. Please return this form in the euctosed postage paid envelope.
This will enable us to obtain any document(s) relative ~to your claim.
Thank you ~or your anticipated cooperation.
Sincerely,
COB Department
Keystone Health Plan Central
I, James L. Miller , hereby authorize the release of any information relative
to the automobile accidenffinjm~ on Jan. 26. 2003 to Keystone Health Plan Central or
their properly authorized agents and/or members.
Signature ~ ~ ~
Parent &~5~ardian of Samantha Jo Miller
Dat. e 03/26/03
P.O. Box 898812
Camp Hill, PA 17089-8812
www.khpc,com
February 28, 2003
James Miller
296 Old Stonehouse Road
Carlisle, PA 17013
Member: Samantha Miller
KHP Central I.D. #: 16848412703
Dear KHP Subscriber:
Keystone Health Plan has recently been advised that you were injured in what is reported as an
"automobile accident related ....~njury.
Your Keystone Health Plan contract has an automobile accident exclusion. If you were injured in
some way relating to an automobile, then your automobile insurance carrier is responsible for your care
until your benefit limit has been met.
Keystone Health Plan must be reimbursed for money that KItP has paid for your doctor's bills, that
have also been paid by your auto carrier.
Date of Accident: January 26, 2003
Briefly describe Injury: Fractured cervical vertebra, fractured right collar bone &
clavical, multiple fractured rib~, 2 collapsed lungs, ~. ~ed s~leen, bruised
l~ver, ~ractured lumbar vertebrae, fractured thoracic vei-~_Dra, dislocated right
la~c~ration of rlq_ht .lec~ ~' ' _ ~
Automobile Carrier: -~rie insurance Group
Name
1~0 Erie Insurance Place, Erie, PA 16530
Address
Q10 2508244 H Erie Claim No.
Auto Policy Number Auto Claim Number
Have the auto benefits exhausted? ~Ye~ No
If yes, please send a copy of the exhausUon letter.
of Samantha Jo Miller
010170661624
717- 2,45-0164
Phone Number (Tnclude area code)
03/26/03
Date
\ll7cl-cob
Subscriber
Agreement
IMPORTANT
Benefits described in this
agreement are covered only
when provided or authorized
by the primary care physician.
Keystone Health Plan Central, Inc.
P.O. Box 898812
Camp Hill, PA 17089-8812
(717) 763-3894 or (800) 622-2843
Independeut Licensee of the Blue Cross and Blue Shield Association
KC520 11-94
Independent Licensee of the Blue Cro~s and Blue Shield Association,
Upon payment in advance of the applicable
premium, Keystone Health Plan Central, Inc. agrees
to make payment for those Covered Services
performed as set forth in this Agreement. This
Agreement is renewable subject to the consent of
Keystone Health Plan Central, Inc.
A CORPORATION OPERATING UNDER THE
SUPERVISION OF THE INSURANCE
DEPARTMENT AND THE DEPARTMENT OF
HEALTH OF THE COMMONWEALTH OF
PENNSYLVANIA.
KEYSTONE HEALTH PLAN CENTRAL
SUBSCRIBER AGREEMENT
TABLE OF CONTENTS
Page
ARTICLE I
DEFINITIOI',IS ......................................................... 1
ARTICLE II
BENEFITS ............................................................. 5
Outpatient Services ........................................... 5
Inpatient Services ............................................ 10
Emergency Services ........................................15
ARTICLE III
EXCLUSIONS ....................................................... 16
ARTICLE IV
GENERAL PROVISIONS ...................................... 19
Eligibility and Enrollment ....................................... 19
Effective Date of Coverage .................................. 21
Multiple Coverage ............................................... 22
Limitations .......................................................... 23
Relationship of Parties ......................................... 23
Payment of Benefits .............................................. 23
Identification Card ........................................... 23
Reports and Records ....................................... 23
Member' Liability .............................................. 24
Determination of Medical Necessity ................. 24
Assignment ..................................................... 24
Coordination of Benefits .................................. 24
Subrogation ..................................................... 26
Waiver of Liability ........................................... 27
Legal Action .................................................... 27
Grievance Procedure ....................................... 27
Subscriber Agreement ........................................... 28
Entire Contract ............................................... 28
Premium Rate ................................................. 29
Change,s of Premium Rate ............................... 29
Termination of Group ...................................... 29
Termination of
Subscribers and Members ........................... 29
Obligations on Termination .............................. 30
Reinstatement ................................................. 30
Other Changes in Status ................................. 30
Erroneous Payments .......................................30
Conversion ..................................................... 30
Continuation of Coverage ................................ 31
Miscellaneous ............................................... 32
Schedule of Copayments ...................................... 34
ARTICLE I - DEFINITIONS
For the purpose of this Subscriber Agreement (the
"Agreement"), the terms below have the following meanings:
1. ~AFTER HOURS PRIMARY CARE PHYSICIAN OFFICE
VISIT - An office visit to the Primary Care Physician
occurring during hours other than those published in the
newest edition of the Keystone Health Plan Central
Physician r~,irectory. Each After Hours Primary Care
Physician Office Visit shall be subject to a copayment
Please refer ~o the schedule of copayments.
BENEFIT MAXIMUM - The greatest amount payable by
t(HP Central for a specific Covered Service under this or a
prior KHP Central contract providing payment for such
Covered Service.
3 BENEFITS (See COVERED SERVICES)
4~ COPAYMENT means the amount required to be paid by a
Member in connection with the Covered Services set forth in
this Agreement. Copayments, if any, are identified in the
Schedule of Copayments or in the applicable Rider to this
Agreement.
5 COVERED SERVICES means the Benefits described ~n
Article II of this Agreement.
6. DEPENDENT - Any member of a Subscriber's family who
meets the applicable eligibility requirements, is enrolled
hereunder through submission of a properly completed
Enrollment Form, and for whom, or on whose behalf, the
appropriate premium payment has been received by
Keystone Health Plan Central (KHP Central),
7 DETOXlFICATION is the process whereby an alcohol or
drug intoxicated or alcohol or drug dependent person is
assisted, in a facility licensed by the Department of Health,
through the, period of time necessary to eliminate, by
metabolic o,' other means, the intoxicating alcohol or drug,
alcohol or drug dependency factors, or alcohol in
combination with drugs, as determined by a licensed
physician, while keeping the physiological risk to the patient
at a m~nimum
EFFECTIVE DATE OF COVERAGE means the date
coverage under this Agreement begins as shown on the
records of KHP Central
9
EMERGENCY - An Emergency Is an accidental injury or the
sudden and unexpected onset of a condition which poses a
$~gnificant jeopardy to the Member's health, requiring
~mmed~ate medical or surgical care Heart attacks, strokes,
po~somngs, loss of consciousness or respiration, and
convulsions are examples of rned~ca[ emergencies
10. ENCOUNTER FORM means the written report submitted to
KHP Central on a form provided by KHP Central on which
all Covered Services provided to Members by the Primary
Care Physician are identified.
11. ENROLLMENT FORM means the properly completed,
written request for membership or enrollment submitted on
a form provided by KHP Central, together with any
amendments or modifications thereof.
12. EQUIVALENT PARTIAL SESSION VISIT - A visit
consisting of a period of 20-30 minutes devoted to individual
or family medical psychotherapy for the treatment of
problems related to substance abuse, with continuing
medical diagnostic evaluation, and drug management when
indicated, to include individual psychoanalysis, insight
oriented, behavior modifying or supportive psychotherapy.
Two Equivalent Partial Sessions equal one Full Session
Visit.
13 EXPERIMENTAL/INVESTIGATIVE The use of any
treatment, procedure, facility, equipment, drug, or drug
usage device or supply which KHP Central, relying on the
advice of the general medical community which includes but
is not limited to medical consultants, medical journals
and/or governmental regulations does not accept as
standard medical treatment of the condition being treated, or
any such items requiring federal or other governmental
agency approval which approval has not been granted at the
time the services were rendered
14 FULL SESSION VISIT - A visit consisting of a period of
45-50 minutes devoted to individual or family medical
psychotherapy for the treatment of problems related to
substance abuse, with continuing medical diagnostic
evaluation, and drug management when indicated, to
include individual psychoanalysis, insight oriented, behavior
modifying or supportive psychotherapy.
15¸
GROUP - The party entering into a contract with KHP
Central on behalf of the Members, including the employer or
representative of and remitting agent for the Members who
collects and remits premium payments on behalf of the
Members.
16, GROUP CONTRACT means an agreement between KHP
Central and a Group pursuant to which KHP Central
coverage under this or other applicable KHP Central
Subscriber Agreement is made available to persons eligible
to enroll in KHP Central's programs,
17. GROUP OPEN ENROLLMENT PERIOD means those
periods of time established by the Group and KHP Central
from time to time, but no less frequently than once in any 12
consecutive months, during which eligible persons who have
not previously enrolled with KHP Central may do so.
2
18. HOME HEALTH AGENCY is an organization licensed by
the Commonwealth of Pennsylvania to render home health
care Services to Members.
19. HOSPICE CARE - Custodial care rendered to a terminally ill
member with a life expectancy of six (6) months or less.
20. HOSPITAL - any institution duly licensed, certified and
operated as a Hospital. In no event shall the term Hospital
include a convalescent facility, nursing home, or any
institution or part thereof which is used as a convalescent
facility, rest facility, nursing facility or facility for the aged.
21. HOSPITAL SERVICES (except as limited or excluded
herein) are those acute-care Covered Services furnished by
a Hospital or Skilled Nursing Facility which are authorized
by a KHP Central Primary Care Physic[an and set forth in
Article I1, Benefits,
22, INFERTILITY - The diminished or absent capacity to
produce offspring regardless of underlying cause, including
but not limited to diminished or absent capacity to conceive
23. INPATIENT means a Member who is admitted as a bed
patient in a Hospital, a Rehabi[itation Hospital, a Skilled
Nursing Facility or a Substance Abuse Treatment Facility.
24. KEYSTONE HEALTH PLAN CENTRAL (KHP Central) is a
health maintenance organization which arranges for the
provision c,f Covered Services to Members in a KHP Central
Service Area,
25. MEDICAID means Hospital or medical insurance benefits
provided by the United States Government under Title XIX
of the Social Security Act of 1965, as amended.
26. MEDICAL DIRECTOR means a physician designated by
KHP Central to monitor appropriate utilization and quality of
covered services received by Members.
27. MEDICALLY NECESSARY OR MEDICAL NECESSITY
means the appropriate and necessary Covered Services as
determined by the Primary Care Physician and KHP Central
which are rendered by a Provider to a Member for a
condition requiring, according to generally accepted
principles of good medical practice, the diagnosis or direct
care treatment of an illness or injury and which are not
provided only as a convenience.
28 MEDICARE means Hospital or medical insurance benefits
provided b,y the United States Government under Title XVlll
of the Social Security Act of 1965, as amended,
29. MEMBER means an individual who is contractually entitled
to receive Covered Services arranged by KHP Central under
this Agreement.
30. OUT OF AREA SERVICES are those Covered Services
provided outside KHP Central's Se~'ice Area. Covered
Services are limited to Emergency Services and Covered
Services that are arranged or authorized by a KHP Central
Primary Care Physician and/or the KHP Central Medical
Director.
31. OUTPATIENT means a Member who receives Covered
Services or supplies while not an Inpatient
32.
PARTIAL HOSPITALIZATION means the provision of
medical, nursing, counseling or therapeutic Covered
Services on a planned and regularly scheduled basis in a
facility licensed as a substance abuse treatment program by
the Department of Health, designed for a patient or ctient
who would benefit from more intensive Covered Services
that are offered in Outpatient treatment but who does not
require Inpatient care.
33. PARTICIPATING PROVIDER means a physician, allied
health professional, Hospital, Skilled Nursing Facility,
Rehabilitation Hospital, Home Health Agency, or any other
health care institution or practitioner, licensed by the
Commonwealth of Pennsylvania, with which KHP Central
has arranged to provide Covered Services to Members.
34. PRIMARY CARE PHYSICIAN means a duly licensed doctor
of medicine or osteopathy who has a contract with KHP
Central under this Agreement to supervise, coordinate and
provide initial and basic care to members, initiate their
referral for a specialist care and maintain continuity of
patient care.
35. REHABILITATION HOSPITAL is a facility Provider which is
engaged in providing rehabilitation Services on an Inpatient
basis.
36. REIMBURSEMENT VALUE means the amount charged or
the amount KHP Central has expended for a particolar
health service in the geographical area ~n which it is
performed.
37 SERVICE AREA means the geograph~ca~ areas as
approved by the State within which KHP Central arranges
for provision of Covered Services to Members
38. SKILLED NURSING FACILITY - An institution, or a distinct
part of an institution, facility, rest facility, or facility for the
aged, which is licensed as a Skilled Nursing Facility by the
Commonwealth of Pennsylvania and approved by KHP
Central
39. SUBSCRIBER means a Member whose employment or
other status, except for family dependency, is the basis for
eligibility for enrollment in KHP Central.
40. SUBSCRIBER DATA CHANGE FORM means a form upon
which the written submission to KHP Central of changes in
Subscriber data affecting Member eligibility is made This
form may be obtained from the employer or directly from
KHP Ceritral.
41.SUBSTANCE ABUSE - The use of alcohol or other
addictive drugs which produces a pattern of pathological use
causing impairment in social or occupational functioning or
which produces physiological dependency evidenced by
physical tolerance or withdrawal. Drugs shall be defined as
addictive drugs and drugs of abuse listed as scheduled
drugs in the Pennsylvania Controlled Substances, Drug,
Device and Cosmetic Act.
42. SUBSTANCE ABUSE TREATMENT FACILITY - A facility
Provider which is licensed by the Department of Health and
approved by the Joint Commission on the Accreditation of
Hospitals and by KHP Central or its designee which is
primarily engaged in providing Detoxification and/or
rehabilitation treatment for alcoholism and/or drug abuse
ARTICLE II - BENEFITS
Subject to the terms, conditions, definitions and exclusions
specified in this Agreement and subject to the payment by
Members of the applicable Copayments, if any, Members shall
be entitled to receive the Covered Services listed below
Services will be covered by KHP Central only if they are
Medically Necessary, and, except for emergencies, are provided
or authorized by the Member's Primary Care Physician or KHP
Central.
OUTPATIENT SERVICES
ALLERGY TESTING AND TREATMENT Allergy tests and
testing materials and treatment, when a~thorized by the
Primary Care Physician
AMBULANCE SERVICES Medically Necessary ambulance
services when ordered or authorized by the Primary Care
Physician and KHP Central. In an Emergency, the Primary
Care Physician's prior authorization is not required.
ANESTHESIA Anesthesia Services when performed in
connectiion with Covered Services which have been
authorized by the Primary Care Physician and KHP Central
4 CHEMOTHEPJ~PY Federally approved chemotherapy
drugs, the administration of these drugs and all associated
laboratory tests/procedures when provided or authorized by
the Primary Care Physician and KHP Central.
DIAGNOSTIC, LABORATORY and X-RAY SERVICES
Medically Necessary x-ray and laboratory tests, procedures,
services and materials, including diagnostic x-rays,
fluoroscopy, and electrocardiograms when authorized or
performed by the Primary Care Physician and/or authorized
by KHP Central.
DIALYSIS Medically Necessary dialysis services when
authorized by the Primary Care Physician and approved by
KHP Central and when provided at the Hospital, a
free-standing renal dialysis facility which has been approved
by KHP Central or, with KHP Central's approval, in the
home. In the case of home dialysis, services will include
equipment, training, and medical supplies. The decision to
purchase or rent necessary equipment~for home dialysis will
be made by KHP Central. When the Member becomes
eligible for Medicare coverage of dialysis, coverage will be
transferred to Medicare coverage.
HEARING SCREENING Hearing screening for diagnostic
purposes, when provided or authorized by the Primary Care
Physician. (SeeArtic[e III, Exclusions.)
HOME HEALTH CARE Care provided by home health care
personnel in the Member's home if located within the
Service Area, determined to be Medically Necessary, and
authorized by the Primary Care Physician and KHP Central.
Such care is limited to 100 visits per calendar year. Private
duty nursing will only be covered if specifically approved in
advance by the KHP Central Medical Director. Homemaker
services or other non-medical services are not covered.
HOME VISITS Physician visits to the Member's home, if
within the Service Area, when performed or authorized by
the Primary Care Physician. Members may be required to
pay a Copayment for each home visit. Please refer to the
Schedule of Copayments.
10. HOSPICE CARE Hospice care services for a terminally ill
Member with a life expectancy of six (6) months or less
when authorized by the Primary Care Physician. Subject to
a Benefit Maximum of $7,500.
11. IMMUNIZATIONS Medically Necessary adult
immunizations and pediatric immunizations as provided for
below when provided or authorized by the Primary Care
Physician (except those required for foreign travel).
Coverage will be provided for those child immunizations,
including the immunizing agents, which, as determined by
the Department of Health, conform with standards of the
(Advisory Committee on Immunization Practices of the
Center for Disease Control) United States Department of
Health and Human Services. Coverage for these child
immunizations will not be subject to Copayments or Benefit
Maximums.
12. INDIVIDUAL CASE MANAGEMENT KHP Central may
. elect to arrange for services under this Subscriber
Agreement through professional or facility providers
pursuant to an individualized treatment plan. Any such
arrangements shall be made solely at KHP Central's
discretion and only when and for so long as it determines
that the alternative services are Medically Necessary and
cost effective. In no event shall KHP Central be obligated to
provide such alternative services at a total cost greater than
for services to which the Member would otherwise be
entitled under this Subscriber Agreement. KHP Central's
election to provide services in such a manner shall not
obligate it to continue to provide the same or similar
services for that or any other member.
13. INDIVIDU~-',LIZATION OF BENEFITS Under certain
circumstances, KHP Central may be able to arrange
alternative services for Members by providing services not
specified in this Agreement. KHP Central may provide such
alternative services at its sole discretion, and only when and
for so long as it determines that the alternative services are
Medically Necessary and cost effective. The provision of
alternative services in a specific situation shall not obligate
KHP Cenl~rai to provide the same or similar services in
another situation; nor shall it be construed as a waiver of
KHP Central's right to administer this Subscriber Agreement
in accorda[nce with its express terms.
14. INFERTILITY Infertility counseling, testing and services,
including artificial insemination, but excluding in vitro
fertilization, subject to a copayment of 50% of the cost of
treatment, with a Benefit Maximum of $2,500, including
injectable~ related to infertility services.
15. INJECTIONS Injectable medications for the treatment oran
illness or injury administered in a physician's office as
deemed appropriate by the Primary Care Physician.
16. MAMMOGRAMS One baseline mammogram at or after 35
years of age; one mammogram in each calendar year at 40
years of age and older; and additional mammography
services es authorized by the Primary Care Physician.
17. MENTAL HEALTH CARE Outpatient mental health care,
as deterrnined by the Primary Care Physician and KHP
Centrel and/or its designated agent to be necessary and
appropriate for short term evaluation and/or crisis
intervention, for up to twenty (20) visits per Member in a
calendar year. Each Outpatient mental health visit will be
subject to a Copayment. Please refer to the Schedule of
Copayments.
18. NEWBORN CARE Care of a newborn child of a member for
a period of thirty-one (31) days following birth, [f medically
7
necessary and approved by the Primary Care Physician.
Such care shall include routine nursery care, prematurity
services, preventive health care services, as well as
coverage for injury or illness, including the necessary care
and treatment of medically diagnosed congenital defects
and birth abnormalities. Continuing care is covered only if:
a) the newborn is eliaible for enrollment; b) the newborn is
enrolled within thirty-one (31) days of birth; and c)
appropriate premium payments from the date of birth are
received.
19. NURSE MIDWIVES The services of a nurse midwife are
covered when authorized by the Primary Care Physician and
KHP Central.
20. OBSTETRICAL CARE Obstetrical care including pre- and
post-natal care, complications of pregnancy and childbirth.
Members may be required to pay a Copayment. Please
refer to the Schedule of Copayments or copay riders. (See
Article III, Exclusions.)
21. OFFICE VISITS Office visits performed or authorized by the
Primary Care Physician. Members may be required to pay
a Copayment for each office visit. Please refer to the
Schedule of Copayments or copay riders.
22. ORAL SURGERY Limited oral surgical procedures in an
Outpatient setting when approved by a Primary Care
Physician and KHP Central and required in connection with
the following:
A. accidental injury to the jaw or structures contiguous to
the jaw, including accidental injury to the teeth, provided that
care or treatment is sought within twenty-four (24) hours of
the accident causing such injury;
B. the correction of a non-dental physiological condition
which as resulted in severe functional impairment; and
C. treatment for tumors and cysts requiring pathological
examination of the jaws, cheeks, lips, tongue, roof and floor
of the mouth. (See Article I[I, Exclusions.)
23. PREVENTIVE HEALTH SERVICES Preventive health
services, including periodic health assessments, well child
care, and periodic Papanicolaou (PAP) tests, according to
schedules approved by KHP Central, when provided or
authorized by the Primary Care Physician or when
authorized by KHP Central.
24. RADIATION THERAPY Radiation therapy services, when
provided or authorized by the Primary Care Physician and
KHP Central.
25. REFERRALS Referrals to Participating Providers when
authorized by the Primary Care Physician. Referrals to
non-participating specialists and other du~y licensed allied
health care personnel will be covered only when authorized
by the Primary Care Physician and KHP Central Self
referrals ars excluded except in the case of Emergencies.
26~SHORT-TERM REHABILITATION THERAPY SERVICES
Occupational, physical, respiratory and speech rehabilitation
therapy on an Outpatient basis, when authorized by the
Primary Care Physician and KHP Central. These
rehabilitation therapy Services are limited to treatment for
conditions which, in the judgment of the Primary Care
Physician and KHP Central, will result in significant
improvement. These therapies are limited to 60 days from
initiation of treatment per condition, per lifetime. Short term
rehabilitation therapy services include:
A. Occupational Therapy when provided by a licensed
provider acting within the scope of such license;
B. Physical Therapy when provided by a licensed provider
acting within the scope of such license;
C. Respiratory Therapy when provided by a licensed
provider acl:ing within the scope of such license;
D. Speech Therapy when provided by a licensed provider
acting within the scope of such license; (See Article HI,
Exclusions.)
27. STERILIZATION - Outpatient vasectomies and tubal
ligations are covered if Medically Necessary, as determined
by the Medilcal Director.
28. SUBSTANCE ABUSE - Diagnosis and medical treatment
for the abuse of or addiction to alcohol or drugs when
determined to be Medically Necessary and referred by the
Primary Care Physician and approved by KHP Central
and/or its designated agent, to include:
A. Diagnostic Services, including psychiatric, psychological
and medical laborato~ tests;
B. Services provided by a staff Physician, Psychologist,
Registered or Licensed Practical Nurse, and/or Certified
Addictions Counselor;
C Rehabi;litation therapy and counseling;
D Family counseling and intervention;
E. Drugs, medicines, supplies and use of equipment
provided b,.t a Substance Abuse Treatment Facility.
Services for treatment of ali forms of Substance Abuse are
limited to sixty (60) outpatient Full Session Visits, Equivalent
Partial Session Visits, or Partial Hospitalization Sessions
per year, 'with a lifetime limit of one-hundred and twenty
(120) Full Session Visits Each Equivalent Partial Session
Visit will count as one-half visit against the annual maximum
of sixty (60) Outpatient Full Session Visits. in addition,
thirty (30) Outpatient Visits or Partial Hospitalization
Sessions per calendar year may be exchanged on a
two-for-one basis to secure up to fifteen (15) additional
non-hospital, residential substance abuse treatment days,
which are in addition to the annual and lifetime maximums
described in Article II, INPATIENT SERVICES. Outpatient
substance abuse treatment visits may be subject to a
Copayment. Please refer to the Schedule of Copayments.
(See Article III, Exclusions).
29. SURGERY Surgical services required for treatment of
disease or injury when authorized by the Primary Care
Physician and KHP Central and performed by a KHP Central
Participating Provider and at a KHP Central participating
facility. Non-participating providers or facilities may be
approved by the Medical Director and/or KHP Central if the
required services are not available from participating
providers or facilities.
30. VISION SCREENING Vision screening for diagnostic
purposes when provided by the Primary Care Physician.
(See Article III, Exclusions.
INPATIENT SERVICES
ANESTHESIA Anesthesia services only when performed in
connection with Covered Services which have been
authorized by the Pdmary Care Physician and KHP Central.
CHEMOTHERAPY Federarly approved chemotherapy
drugs and all associated laboratory tests/procedures when
provided or authorized by the Primary Care Physician and
KHP Central.
DIAGNOSTIC, LABORATORY AND X-RAY SERVICES
Medically Necessary x-ray and laboratory tests, procedures,
services and materials, including diagnostic x-rays,
fluoroscopy, and electrocardiograms when authorized by the
Primary Care Physician and KHP Central.
DIALYSIS Medically necessary dialysis services and
supplies when authorized by the Primary Care Physician
and approved by KHP Central. When the Member becomes
eligible for Medicare coverage of dialysis, KHP Central
dialysis coverage will be transferred to Medicare coverage.
DRUGS AND MEDICATIONS Drugs, medications, and
injections received and used as an inpatient in connection
with Covered Services which have been authorized by the
Primary Care Physician.
HEARING SCREENING Hearing screening for diagnostic
purposes when provided or authorized by the Primary Care
Physician and KHP Central. (See Article Iii, Exclusions.)
HOSPITAL Un[imited Inpatient days in a Hospital for
Medically Necessary treatment when authorized by the
Primary Care Physician or KHP Central, except as noted
herein for Inpatient mental hea~th services and short-term
- rehabilitative Services. [See inpatient Services, Article 11(21)
and (24).] Except in Emergencies, Hospital admissions
must be coordinated through the Member's Primary Care
Physician. When' authorized by the Primary Care Physician
and KHP Central, covered Hospital Services include:
A. Semi-private room and board (or private or specialty
accommodations when certified as Medically Necessary by
the attending physician, the Primary Care Physician and
KHP CentraQ.
General nursing care.
C. Privata duty nursing care when Medically Necessary
and authorized by the Primary Care Physician and KHP
Central.
D. Drugs, medications, and biologicals.
E. Meals (including special diets when Medically
Necessary).
F. Use of the operating room and related facilities.
G. Use of intensive care or cardiac units and related
Services.
H. Oxygan Services.
I. Administration of whole blood and blood plasma to
include the processing and preparation.
J. Medically Necessary supplies, appliances and
equipment. (See Article Ill, Exclusions.)
iMMUNIZATIONS Medically Necessary adult
immunizations and pediatric immunizations as provided for
below when provided or authorized by the Primary Care
Physician (except those required for foreign travel).
Coverage will be provided for those child immunizations,
including the immunizing agents, which, as determined by
the Department of Health, conform with standards of the
(Advisory Committee on Immunization Practices of the
Center for Disease Control) United States Department of
Health and Human Services. Coverage for these child
immunizations will not be subject to Copayments or Benefit
Maximums.
IMPLAN'rABLE DEVICES Surgicatly implanted prosthetic
devices when determined to be Medically Necessary by the
Primary Care Physician and KHP Central. (See Article III,
Exclusions.)
10. INDIVIDUAL CASE MANAGEMENT KHP Central may
elect to arrange for services under this Subscriber
Agreement through professional or facilities providers
(pursuant to an individualized treatment plan). Any such
arrangements shall be made solely at KHP Centrai's
discretion and only when and for so long as it determines
that the alternative services are Medically Necessary and
cost effective. In no event shall KHP Central be obligated to
provide such alternative services at a total cost greater than
for services to which the Member would otherwise be
entitled under this Subscriber Agreement. KHP Central's
election to provide services in such a manner sha~l not
obligate it to continue to provide the same or similar
services for that or any other member.
11.INDIVIDUALIZATION OF BENEFITS Under certain
circumstances, KHP Central may be able to arrange more
effective medical care for Members by providing services
not specified in this Agreement. KHP Central may provide
such a~ternative services at its sole discretion, and only
when and for so long as it determines that the alternative
services are Medically Necessary and cost effective. The
provision of alternative services in a specific situation shall
not obligate KHP Central to provide the same or similar
services in another situation; nor shall it be construed as a
waiver of KHP Central's right to administer this Subscriber
Agreement in accordance with its express terms.
12. INPATIENT PHYSICIAN CARE Generally accepted and
Medically Necessary health services performed, prescribed,
or supervised by physicians within a hospital for registered
bed patients, including diagnostic and therapeutic care.
13. MENTAL HEALTH CARE Inpatient mental health care
services in a Provider facility when authorized by the
Primary Care Physician and KHP Central and/or its
designated agent, limited to thirty (30) inpatient days per
Member in a calendar year. (See Article Ill, Exclusions.)
NEWBORN CARE Care of a newborn child of a member for
a period of thirty-one (31) days following birth, if medically
necessary and approved by the Primary Care Physician.
Such care shall include routine nursery care, prematurity
services, preventive health care services, as well as
coverage for injury or illness, including the necessary care
and treatment of medically diagnosed congenital defects
and birth abnormalities. Continuing care is covered only if:
a) the newborn is el/q/hie for enrollment; b) the newborn is
enrolled within thirty-one (31) days of birthl and c)
appropriate premium payments from the date of birth are
received.
15. NURSE MIDWIVES The services of a nurse midwife are
covered when authorized by the Primary Care Physician and
KHP Central.
t6. OBSTETRICAL CARE Obstetrical care including pre- and
post-natal oare, complications of pregnancy and childbirth.
(See Article III, Exclusions.)
17. ORAL SURGERY Limited oral surgical procedures when
approved i.,y the Primary Care Physician and KHP Contra{
and required in connection with the following;
A. accidental injury to the jaw or structures contiguous to
the jaw (exoluding teeth);
B. the correction of a non-dental physiological condition
which has resulted in a severe functional impairment; and
C. treatment for tumors and cysts requiring pathological
examination of the jaws, cheeks, lips, tongue, roof and floor
of the mouth.
18. ORGAN TRANSPLANT Medically Necessary
transplantE~tion services for member recipients when not
deemed to be Experimental/Investigational and authorized
by the Primary Care Physician and KHP Central.
Determination of medical necessity shall also take into
account the procedure's suitability for the potential member
and availa~)ility of appropriate facilities for performing such
procedures. KHP Central may arrange for certain transplant
procedure.~i in accordance with the Individual Case
Management provision of this Agreement. Services required
by a Member related to organ donation when the Member
serves as the donor are not covered (See Article III,
Exclusions).
If not paid for by any other source, the following services of
donors donating organs to Member recipients are covered:
A. the removal ofthe organ from the donor,
B. donor preparatory pathologic and/or medical
examinations,
donor post-surgical care.
19. RADIATION THERAPY Radiation therapy services when
provided or authorized by the Primary Care Physician and
KHP Central.
20. REFERRALS Referrals to participating specialists when
authorized by the Primary Care Physician. Referrals to
non-participating specialists and other duly licensed allied
health care personnel will be covered only when authorized
by the Prirnary Care Physician and KHP Central
21.SHORT-TIERM REHABILITATION THERAPY SERVICES
Occupational, physical, respiratory and speech rehabilitation
therapy on an Inpatient basis, when authorized by the
Primary Care Physician and KHP Central. These
rehabilitation therapy services are limited to treatment for
conditions which, in the judgment of the Primary Care
13
Physician and KHP Central, will result in significant
improvement. These therapies are limited to 60 days from
initiation of treatment per condition, per lifetime. Short term
rehabilitation therapy services include:
A. Occupational Therapy when provided by a licensed
provider acting within the scope of such ~icense;
B. Physical Therapy when provided by a licensed provider
acting within the scope of such license;
C. Respiratory Therapy when provided by a licensed
provider acting within the scope of such license;
D Speech Therapy when provided by a licensed provider
acting within the scope of such license (See Article III,
Exclusions).
22. SKILLED NURSING FACILITY SERVICES Skilled Nursing
Facility Services up to 180 days per year when authorized
by the Primary Care Physician and KHP Central Charges
which relate to non-custodial care and Covered Services
which are Medically Necessary and not excluded elsewhere
in this Agreement (see Article III, Exclusions) are covered.
Custodial or domiciliary care in a Skilled Nursing Facility or
elsewhere is not covered. Benefits are limited to semi-
private accommodations or an allowance equal to the
facility's most frequent established charge for semi-private
accommodations which may be applied to the cost of
private accommodations.
23. STERILIZATION Inpatient vasectomies and tubal ligations
are covered only if Medically Necessary, as determined by
the Medical Director, or if the procedure is coincident with
hospitalization for another reason (i.e., post-partum tubal
ligation).
24. SUBSTANCE ABUSE Diagnosis and short-term medical
treatment for the abuse of, or addiction to, alcohol or drugs
including Detox[fication, in an acute care Hospital or a
Substance Abuse Treatment Facility for the abuse of or
addiction to alcohol, when determined to be Medically
Necessary and arranged through appropriate referral by the
Primary care Physician. As a separate benefit,
non-medical, rehabilitative services for substance abuse will
be covered in a Substance Abuse Treatment Facility when
determined to be Medically Necessary and arranged through
appropriate referral by the Primary Care Physician.
inpatient Benefits include:
A. Detoxification;
B. Lodging and Dietary Services;
C. Diagnostic Services, including psychiatric, psychological
and medical laboratory tests;
14
D. Services provided by a staff Physician, Psychologist,
Registered or Licensed Practical Nurse, and/or Certified
Addictions Counselor;
E. Rehabilitation therapy and counseling;
F. Family counseling and intervention;
G. Drugs, medicines, supplies and use of equipment
provided by the Substance Abuse Treatment Facility.
For all forms of Substance Abuse, the detoxification benefit
is limited to no more than seven (7) days per admission and
four (4) admissions per lifetime. Similarly, the rehabilitative
Services benefit is limited to thirty (30) days per year in a
Substance Abuse Treatment Facility, with a lifetime limit of
ninety (90) days. (See Article II1, Exclusions.)
25. SURGERY Surgical services required for treatment of
disease or injury when authorized by the Primary Care
Physiciar~ and KHP Central and performed by a KHP Central
participating provider and at a KHP Central participating
facility. Non-participating providers or facilities may be
approved by the Medical Director.
26. VISION SCREENING Vision screening for diagnostic
purposes when provided or authorized by the Primary Care
Physician and KHP Central. (See Article III, Exclusions.)
EMERGENCY SERVICES
Within the Service Area. Medical care is available through
KHP Central Primary Care Physicians 7 days a week, 24
hours a day. Under almost all circumstances, the Member
must obl~ain treatment or authorization for treatment from
the Prin'~ary Care Physician or his designated covering
physician.
In the event the member experiences an Emergency
condition, the member should contact their Primary Care
Physician. If they cannot, the Member should seek medical
care from the most readily available source.
If a Mernber obtains care in what they believe to be an
Emergency without obtaininq authorization from the Primary
Care Physician, the Member will be requested to provide
information about the occurrence. KHP Central will then
review the facts of the situation and the nature of the
services provided. Only if KHP Central determines the
services constitute an Emergency as defined in this
Agreement will charges incurred be covered. Each
emergency room visit shall be subject to a copayment
Please refer to the Schedule of Copayments.
An Emergency is an accidental injury or the sudden
onset oll a condition which poses a significant jeopardy
to the Nlember's health, requiring immediate medical or
surgical care. Heart attacks, strokes, peisonings, loss
of consciousness or respiration, and convulsions are
examples of medical emergencies.
15
Outside the Service Area. Subject to the Continuing Care
provisions set forth below, the charges for Medically
Necessary Covered Services which are the~ result of an
Emergency occurring outside the Service Area are covered
only if, in the determination of KHP Central:
(1) the Member could not have anticipated the need for
such services prior to leaving the Service Area, and
(2) delaying care until the Member could be expected to
return to the care of the Primary Care Physician might
significantly jeopardize the Member's health or life.
Continuing Care. Services of any Provider other than the
Primary Care Physician will be covered only until the
Member can be transferred, without medically harmful
consequences, to the care of the Member's Primary Care
Physician or a specialist designated by the Primary Care
Physician.
ARTICLE III - EXCLUSIONS
The following are excluded from coverage under this
Agreement:
Services or supplies which are:
(A) not provided by or authorized by the Primary Care
Physician;
(B) not Medically Necessary, as determined by the Primary
Care Physician and/or KHP Central, for the diagnosis or
treatment of illness, injury or restoration of physiological
functions,
2. The cost of services or supplies which are payable under
Worker's Compensation or employer's liability laws or other
legislation of similar purpose.
3. Care for military service connected disabilities and
conditions for which the Member is legaily entitled to
services, and for which facilities are reasonably accessible
to the Member.
4 Care for conditions that federal, state or local law requires to
be treated in a public facility.
5 The cost of services covered under the Medicare Act when
Medicare is primary. In such situations, KHP Central or its
designee will file the Member's Medicare claims for health
services. Medicare will pay KHP Central or its designee
directly. However, if for any reason Medicare pays the
Member directly, KHP Central or its designee will bill the
Member for the amount to which the Member is entitled
under Meclicare. However, this exclusion shall not apply
when the group is obligated by law to offer the Subscriber all
the benefits of this contract and the Subscriber so elects this
coverage as primary.
6: The cost of Hospital, medical or other Covered Services
resulting from accidental bodily injuries arising out of a
motor vehicle accident, to the extent such benefits ara
payable under any medical expense payment provision (by
whatever terminology used, including such benefits
mandated by law) of any automobile insurance policy unless
otherwise prohibited by applicable law,
7. Dental care, periodontal care, including but not limited to
treatment of the teeth, extraction of teeth, treatment of
dental abscesses or grenuloma, treatment of gingival
tissues (other than for tumors), dental examinations, and
any other dental product or service unless specifically
provided elsewhere in this Agreement. Anesthesia and
facility charges related to non-covered dental services shall
not be cowgred.
8. Any services related to and rendered in connection with a
non-coverad service shall not be covered.
Treatment of temporomandibular joint syndrome (only
evaluation covered) if dental in nature or not Medically
Necessary as determined by the Primary Care Physician
and/or KHP Central
10. The cost cf any Experimental/Investigative medical,
surgical, or other health care services, procedures or
supplies, including organ transplant procedures deemed to
be Experimental/Investigative will not be covered,
11, Routine physical examination and preparation of specialized
reports solely for insurance, licensing, employment, or other
non-preventive purposes, such as pre-marital examinations,
physicals rot college, camp, sport or travel, which are not
Medically Necessary.
12. Cosmetic surgery, defined as any plastic surgery done
primarily to improve the appearance of any portion of the
body, and from which no improvement in physiologic
function could be reasonably expected.
13. AII rehabilitative therapy except as described in this
Agreement, including but not limited to play and recreational
therapy.
14. AII rout/ns, vision and hearing examinations and services
except as described in this Agreement.
15. Hearing aids, eyeglasses, contact lenses, or the fitting
thereof.
16. Acupuncture
]7
17. Radial keratotomy.
18. Mental health/substance abuse services that are not covered
include: biofeedback; chronic care; court ordered care,
including care as a condition of parole or probation;
educational testing; evaluation testing; hypnosis; interpreter
services; methadone maintenance, mental retardation
services; psychological testing and attention deficit disorder
and other learning disabilities.
19. Immunizations required for foreign travel.
20. Custodial and domiciliary care, residential care, protective
and supportive care including educational services, rest
cures, convalescent care.
21 ..Weight reduction programs, including all diagnostic testing
related to weight reduction programs.
22. Personal or comfort items, including but not limited to,
admission kits, slippers, television, telephone, air
conditioners, humidifiers, barber or beauty services, guest
service and similar incidental services and supplies which
are not Medicaliy Necessary.
23. Normal deliveries outside the Service Area within thirty (30)
days of the expected delivery date.
24. Any procedure or treatment designed to alter physical
characteristics cf the Member to those of the opposite sex,
and any other treatment or studies related to sex
transformations.
25. Treatment of bunions (except capsular or bone surgery), toe
nails, .(except surgery for ingrown nails), corns, calluses,
fallen arches, flat feet, weak feet, chronic foot strain or
symptomatic complaints of the feet, unless deemed
Medically Necessary by the Primary Care Physician and
KHP Central
26 Contraceptive devices, including their insertion and
implantatio~k and birth control pills
27 In vitro fertilization, embryo transplants
28. Reversal of voluntary steril~zetion.
29. Services or supplies for which there is no legal obligation on
the part of the Member to pay
30. Except as specifically provided for in this Agreement,
prosthetic devices, home medical equipment, durable
medical equipment and appliances, including health
services associated with such devices.
31 Prescribed drugs and medications, except those which are
administered to an Inpatient or are provided by a Substance
Abuse Treatment Facility
32. Ambulanee services, untess Medically Necessary as
determined by the Primary Care Physician and KHP Central
33. Whole blood, blood plasma or blood components.
34. Services required by a Member related to organ donation
where the Member serves as the organ donor. Expenses for
donors donating organs to Members are covered only as
described in this Agreement. No payment will be made for
human organs which are sold rather than donated.
35. Court ordered services when not Medically Necessary, as
determined by the Primary Care Physician and KHP Central.
36. Charges for completion of any insurance form.
37. Any Services, supplies or treatments not specifically listed in
this Agreement, except those required by the Pennsylvania
Department of Health as basic health services.
38. Artificial hearts.
39. Surgical aperations or procedures for correction of obesity,
including but not limited to gastric stapling or balloon
procedures.
40. Infertility injectables or other supplies and drugs prescribed
on an out-patient basis for or in connect[on with artificial
insemination.
41.Growth hormones, unless determined to be Medically
Necessary by KHP Central.
42. Services for sleep disorders and sleep therapy.
43. Private duty nurses, except as specified in this Agreement.
44. Charges for failure to keep a scheduled appointment.
45. Any services related to injuries incurred while committing a
felony.
ARTICLE IV - GENERAL PROVISIONS
1. ELIGIBILITY AND ENROLLMENT
A, The ,~ubscriber. To be eligible to be a Subscriber, an
individual must reside in a KHP Central Service Area and:
(1) be a member of an eligible Group who is entitled
to pa~licipate in his Group's health benefits program,
including compliance with any probationary or waiting
period established by the Group; and/or
19
(2) be entitled to coverage under a trust agreement or
employment contract; and/or
(3) having been a Subscriber, leave a Group and
continue KHP Central coverage without interruption.
B. Eligible Dependents. To be eligible to be enrolled as a
Member, a Dependent of a Subscriber must meet all
eligibility requirements established by the Group, be listed
on an EnrollmentJChange Form completed by the
Subscriber, and be:
(1) The Subscriber's legal spouse, or
(2) an unmarried dependent child (including natural
child, legally adopted child, or stepchild) of either the
Subscriber or the Subscriber's spouse, who is under the
age of 19 years of age. Additionally, a dependent child
shall include a child for whom the Subscriber or
Subscriber's spouse is a court-appointed guardian, or
(3) an unmarried Dependent child 19 years of age or
older, who, in the judgment of KHP Central, is incapable
of self-support because of mental or physical handicap
(for which continuing justification is required) and whose
disability occurred prior to age 19, or
(4) an unmarried Dependent child, between 19 and 23
years of age, who resides in the Service Area and is a
full-time student enrolled in and attending an accredited
educational institution.
KHP Central may require appropriate proof of a Dependent's
status before enrolling said Dependent.
C. Newborn children. Newborn children of a Member are
covered under this Agreement for the first thirty-one (31)
days immediately following birth. Coverage after thirty-one
(31) days is contingent upon the newborn being eligible for
enrollment and the Subscriber enrolling the newborn child
as a Dependent within the thirty-one (31) day period and
paying any applicable premium charges due.
O. Enrollment.
(1) Initial Enrollment. During the initial Group
Enrollment Period, each eligible employee shall be
entitled to apply for coverage for himself and eligible
Dependents who must be listed on the
EnrollmentJChange Form provided by KHP Central No
proof of insurability shall be required,
(2) Newly Eligible Employee. Each new employee
of the Group entering employment subsequent to the
Group's initial Effective Date of Coverage shall be
permitted to apply for coverage for himself and e~igible
Dependents within thirty-one (31) days of becoming
~0
eligible, subject to the enrollment regulations in effect
with the Group, without proof of insurability
(3) Newly Eligible Dependents. Any person
attaining eligibility to become a Dependent may be
enrc, lled by the Subscriber by completing and submitting
to KHP Central a signed EnroHmentJChange Form within
thirty-one (31) days of the Dependent's attaining
eligibility. No proof of insurability shall be required.
(4) Group Open Enrollment. A Group Open
Enrollment Period shall be held at least annually at
which time eligible Subscribers and/or eligible
Dependents may enroll as Members under this
Agreement. No proof of insurability shall be required.
(5) Limitation. Persons initially or newly eligible for
enrollment who do not enroll within thirty-one (31) days
of bacoming eligible, or already-eligible Dependents who
do not enroll during a Group Open Enrollment Period
may only be enrolled during a subsequent Group Open
Enrollment Period. Exceptions may be made only by
written consent of the Group and KHP Central
E. Notice of Ineligibility. It shall be the Subscriber's or
Group's responsibility to notify KHP Central of any changes
which will affect the Subscriber's eligibility or that of
Dependants for Services or Benefits under this Agreement
Failure of the Subscriber or Group to notify KHP Central
within thirty (30) days of any such changes shall render
Subscriber and Group liable for any costs of Services or
Benefits provided by KHP Central after the Subscriber or a
Dependant became ineligible to continue coverage under
this Agreement.
F. Rul,es of Eligibility. No person will be refused
enrollment or re-enrollment by KHP Central because of
health status, age {except as provided in Article IV, Section
1.B.), requirements for health Services, or the existence, on
the Effective Date of Coverage under this Agreement, of a
pre-existing physical or mental condition, including
pregnancy. In addition, no Member's coverage shall be
terminated by KHP Central due to health status or health
care needs.
2. EFFECTIVE DATE OF COVERAGE
A. Subject to the payment of applicable premium
payments by the Group for the individuai, KHP Central's
receipt of an EnrollmentJChange Form from or on behalf of
each prospective Member and the provisions of this
Agreemant (except as may be otherwise provided in the
Group Contract), coverage under this Agreement shall
become effective on the earliest of the following dates:
(1) When a person makes written application for
membership on or prior to the date he satisfies the
eligibility requirements of Article IV, Section 1, coverage
shall be effective as of the date the eligibility
requirements are satisfied.
(2) When a person makes written apptication for
membership after the date he satisfies the eligibility
requirements for Article IVl Section 1, coverage will be
effective as of the first day of the calendar month
following the month in which the Enrollment/Change
Form is received by KHP Central, except as otherwise
provided by the Group Contract. In addition, services
shall be provided starting at birth for newborn children of
Members for thirty-one (31) days, and continue in effect
thereafter if the newborn is eligible and enrolled by the
Subscriber within thirty-one (31) days of the newbom's
birth.
(3) Except as otherwise agreed to by Group and KHP
Central, when a person makes written application for
membership during the Group Enrollment Period,
coverage will be on the first day of the calendar month
next following the conclusion of the Group Enrollment
Period.
(4) Except as provided in Article iV, Section 7 hereof,
this Agreement continues in force for the period of one
year from the Effective Date of Coverage as shown on
the records of KHP Central and from year to year
thereafter unless terminated as hereinafter specified,
provided that KHP Central may change the premium
rates as hereinafter provided, with the approval of the
Commonwealth of Pennsylvania.
B. If, on the date on which coverage under this Agreement
becomes effective, the Member is an inpatient in a Hospital,
benefits will be provided under this Agreement to the extent
that they are not provided under a prior group insurance
agreement.
MULTIPLE COVERAGE
A. Workers' Compensation. The Benefits under this
Agreement for Members eligible for Workers' Compensation
are not designed to duplicate any Benefit to which such
Members are eligible under the Workers' Compensation
Law. All sums payable pursuant to Workers' Compensation
for Services provided hereunder to Members are payable to
and retained by KHP Central. It is understood that coverage
hereunder is not in lieu of, and shall not affect, any
requirements for coverage under Workers' Compensation.
B. Medicare. Except as otherwise provided by applicable
federal law, the Benefits under this Agreement for Members
age 65 and older, or Members otherwise eligibie for
Medicare payments, do not duplicate any Benefit to which
such Members are eligible under the Medicare Act, including
Part B of such Act. Where Medicare is the responsible
payor, all sums payable pursuant to the Medicare program
for Services provided hereunder to Members are payable to
and retained by KHP Central.
C. Membera' Cooperation. Each Member shall complete
and submit to KHP Central such consents, releases,
assignments and other documents as may be required by
KHP Central in order to obtain or assure reimbursement
under Medicare or Workers' Compensation. Any Member
who fails to so cooperate (including a Member who fails to
enroll under Part B of the Medicare program where Medicare
is the responsible payor) will be responsible to KHP Central
for the Reimbursement Value of Services subject to this
Section 3, and may be terminated in accordance with Article
IV, Section 7, E.
LIMITATIONS
In the even that, due to circumstances not within the control
of KHP Central, including but not limited to a major disaster,
epidemic, the complete or partial destruction of facilities,
riot, cMl insurrection, or similar causes, the rendition of
Services provided under this Agreement is delayed or
rendered impractical, KHP Central shall make a good faith
effort to arrange for an alternative method of providing
coverage. In such event, KHP Central shall provided
Covered Services covered under this Agreement insofar as
practical, and according to its best judgment; but neither
KHP Central nor Providers shall incur liability or obligation
for delay, or failure to provide or arrange for Services if such
failure or delay is caused by such event(s). Except in
Emergencies, the Primary Care Physician must coordinate
and approve Services to be covered.
5. RELATIONSHIP OF PARTIES
KHP Central Primary Care Physicians maintain the
physician-patient relationship with Members and are solely
responsible to Members for all medical Services. The
relafionship between KHP Central and KHP Central Primary
Care Physicians, and between KHP Central and other
contracting Providers of health Services, is an independent
contract relationship. KHP Central Primary Care Physicians
are no1; agents or employees of KHP Central, nor is any
employee of KHP Central an employee or agent of KHP
Central Primary Care Physicians. KHP Central shall not be
liable for any claim or demand on account of damages
arising out of, or in any manner connected with, any injuries
suffered by the Member while receiving care from any KHP
Central Primary Care Physician or from any Provider to
which the Member has been referred by the Primary Care
Physician or KHP Central.
6. PAYMENT OF BENEFITS KHP Central, in determining whether KHP Central or
another Group health plan has primary liability, the following
will apply:
A. Identification Card. For purposes of identiflca*ion and
specific coverage information, a Member's identification
card must be presented when a service is requested.
B. Reports and Records. The Member consents to and
authohzes any person or organization which provides
Covered Services to Member to furnish to KHP Central and
to other providem of Covered Services, information or
records pertaining to the Member, including but not limited
to records and information regarding the Member's physical
or mental condition, history, or treatment. Further, the
Member consents to and authorizes KHP Central to furnish
such information or records concerning the Member to such
providers of Covered Services and to other individuals or
organizations for peer review or ~ilization review purposes,
and as otherwise required by law. Finally, the Member
agrees that approval by KHP Central of payments for any
Covered Services, facilities, or supplies is contingent on
KHP Central's receipt of such information or records as it
may request.
C. Member Liability. Except when certain Copayment or
other limitations ara specified in this Agreement, the
Member is not liable for any charges for Covered Services
when Covered Services have been authorized by the
Member's Primary Care Physician or the KHP Central
Medical Dirac{or.
D. Determination of Medical Necessity. The Services,
facilities or supplies described in Article II of this Agreement
are covered only when they are Medically Necessary for the
restoration of the Member's health, as determined by the
Primary Care Physician or KHP Central. Any Services
requested by a Member which are not Medicarly Necessary
will not be covered.
E. Assignment. Any rights of a Member to receive
Covered Services or payments under this Agreement are
personal to the Member and may not be assigned to any
person, Provider or entity, without written consent of KHP
Central.
F. Coordination of Benefits With Other Health Care
Plans. If the Member is also entitled to receive Benefits
under any other Group health care plan for services covered
by this Agreement or under any governmental program for
which any periodic premium payment is made by or for the
Member, payments may be coordinated between KHP
Central and the other health care plan. In all cases, KHP
Central will pay benefits first and determine liability later. If
it is determined that KHP Central is the secondary plan,
KHP Central has the right to recover the expense already
paid in excess of its liability as the secondary plan. The
Member will be required to furnish information and to take
such other action as is necessary to assure the rights of
24
(1) If the other plan does not include a coordination of
benefits or non-duplication provision, that plan will be the
primary plan.
(2) If the other plan does include a coordination of
benefits or non-duplication provision:
(a) The plan covering the patient other than as a
Dependent will be the primary plan,
(b) Where both plans cover the patient as a
Dependent child, the plan covering the patient as a
Dependent child of a parent whose date of birth.
excluding the year of birth, occurs earlier in a
calandar year, shall be the primary plan. If both
parents have the same birthday, the plan which
covered the parent longer will be the primary plan. If
the other plan does not include this provision, the
provisions of that plan will determine the order of
benefits.
(c) If the parents are separated or divorced, the
following will apply:
(i) The plan which covers the Member as a
Dependent of the parent with custody will be the
primary plan. The stepparent will have secondary
responsibility and the parent without custody will
have final responsibility.
(ii) Where there is a court decree which
establishes financial responsibility for the health
care expenses of the Dependent child, the plan
which covers the child as a Dependent of the
parent with such financial responsibility will be
the primary plan
(iii) The Benefits of a plan covering the patient
as a laid-off or retired employee or as the
Dependent of a laid-off or retired employee shall
be determined after the Benefits of any other plan
covering such person as an employee shall be
determined after the Benefits of any other plan
covering such person as an employee or
Dependent of such person. If the other plan does
not have the tale regarding laid-off or retired
employees, and if, as a result, the plans do not
agree on the order of benefits, the rule will be
ignored.
(iv) Where the determination cannot be made m
accordance with the preceding paragraphs, the
plan which has covered the patient for the longer
period of time will be the primary plan
2~
(v) Services provided under any governmental
program for which any periodic premium
payment is made by or for the Subscriber shall
always be the primary plan, except where
prohibited by law.
(3) Services under this Agreement for the treatment of
injury arising out of the maintenance or use of a motor
vehicle shall be covered only to the extent that such
Benefits are in excess of, and not in duplication of
Services paid or payable:
(a)under a plan or policy of motor vehicle insurance,
provided that non-duplication as contained herein is
not prohibited by law; or
(b)through the Catastrophic Loss Trust Fund; or
(c)through a program or other arrangement of qualified
or certified self-insurance.
KHP Central may release to or obtain from any person
or organization any information about coverage,
expenses and Benefits which may be necessary to
coordinate Benefits. For the purpose of coordination of
Benefits, if the Member receives services, facilities or
supplies available under this Agreement but not provided
by nor authorized by the Member's Primary Care
Physician, payment will not be made by KHP Central.
This provision does not apply to: an individual health
care plan issued to or in the name of the Member; group
or group-type hospital indemnity benefits of $100 per
day or less; or school accident-type coverage.
Subrogation.
(1) If any Covered Service is provided to the Member
under this Agreement, KHP Central shall be subrogated
and succeed to the Member's rights or recovery with
respect to the Covered Services or supplies involved
against a responsible third party and/or insurance
company.
(2) Subrogation means that if the Subscriber or the
Subscriber's Dependent(s) is injured because of the
negligence or wrong doing of another party, KHP Centrel
has the right to seek recovery of the Reimbursement
Value of related Covered Services provided. The
Member is expected to cooperate with KHP Central and
take any action necessary to protect and to assure the
subrogation rights of KHP Central.
(3) This provision does not apply to an individual
insurance policy covering a Member. There will be no
right of subrogation where prohibited by law.
26
KHP Central may, without consent of or notice to any
person, release to or obtain from any insurance company or
other organization or person any information, with respect to
any person, which KHP Central deems to be necessary for
the purpose of determining its liability under this Agreement,
Any person claiming Benefits under this Agreement agrees
to furnish KHP Central such information as may be
necessary to implement this provision. KHP Central has the
right, at any time, to require such information to be
furnished 1:o it without cost or expense as a condition
precedent to liability for any claim for Covered Services
under the terms of this provision.
H. Waiver of Liability. KHP Central shall not be liable for
injuries resulting form negligence, misfeasance,
nonfeasance or malpractice on the part of any Provider in
the course ~f performing Covered Services for Members.
I. Legal Action. No legal action may be commenced
against KHIP Central with respect to the Agreement until
ninety (90) days after KHP Central has received a properly
completed claim form or Encounter Form, nor may such
action be taken at all later than two years after the Covered
Services or supplies were performed or provided.
J. Grievance Procedure.
Informal Resolution Procedure Members having
concerns, problems or complaints involving Benefits under
this Agreement, the availability or delivery of Covered
Services; the Member's Primary Care Physician or other
providers; t:he operation of KHP Central; or the terms of this
Agreement should contact KHP Central's Member Services
Department:. Staff members wi[I work with the Member to
attempt to resolve concerns or disputes informally. In
communicating with the Member Services Department, the
Member should provide pertinent information regarding their
concerns. Inquiries may be directed to the Member
Services Department at the following address, or by calling
the Department at 1-800-622-2843.
Member Services Department
Keystone Health Plan Central
Post Office Box 898812
Camp Hill, Pennsylvania 17089-8812
If a Member is not satisfied with KHP Central's response
concerning their complaint, the Member may file a formal
grievance. There are two steps in the Keystone Health Plan
Central grievance process.
Formal Grievance Procedure The grievance will first be
reviewed and investigated by the Initial Grievance
Committee., composed of two or more management staff
The member should forward pertinent written information
regarding the grievance to the committee. The committee
27
will provide a written decision within thirty (30) days of its
receipt of a grievance. The Initial Grievance Committee's
decision will be binding, unless the Member appeals the
decision.
The appeal of the Initial Grievance Committee's decision
shall be to the Grievance Review Board. The Grievance
Review Board is established by the Board of Directors and
includes at least one-third Subscribers to the HMO. The
Grievance Review Board will hold an informal hearing in
which the Member (and any other interested party) may
present, in person or in writing, their positions on the
disputed matter. The Member has the right, but is not
required, to attend the hearing. Such a hearing will be held
at a time which is mutually acceptable to the Member, the
Board and any other persons involved. KHP Central will
provide the Member with written information on the hearing
procedures. KHP Central will hold the hearing within thirty
(30) days of receipt of the Member's request. At any stage
of the grievance process, the Member has the right to
request that KHP Central appoint a staff member who has
no direct involvement to assist the Member.
The Grievance Review Board will issue a formal decision
within ten (10) days of the hearing. The Board's decision is
binding unless the Member appeals the decision to the
Bureau of Health Financing and Program Development,
located in the Pennsylvania Department of Health, Room
1026 Health and We[fare Building, Post Office Box 90,
Harrisburg. Pennsylvania 17108-0090, (717) 787-5193.
Grievances usually deal with claim denials and the remedy
sought is payment of the claim by KHP Central However,
m those cases in which a Member believes that serious
medical consequences will arise from KHP Central's failure
to provide the requested health services, the member may
request an expedited review.
To do so, the Member should contact the Member Services
Department, identifying the particular need for an expedited
review. An expedited rewew may be considered:
Urgent Review: Case ~s reviewed by the medical
director and a decision is rendered in writing to the Member
within fifteen (15) days.
Emergency Review: Case is reviewed by the medical
director and a decision is rendered in writing to the Member
within two (2) working days, with initial notification by
telephone, when appropriate
If the medical director's dec~sion is adverse to the Member,
the Member may appeal the decision immediately to the
Medical Review Committee by contacting the Member
Services department
The medical director will contact the Medical Review
Committee to present the Member's case. This committee,
2A
composed of at least two physicians, will review the case
and render an immediate decision. The Member will be
informed via letter and by telephone, when appropriate, The
Member will be informed of the right to appeal the decision
- to the Pennsylvania Department of Health.
SUBSCRIBER AGREEMENT
A. Entire Contract. The entire contract between KHP
Central and the Member consists of the Group Contract, the
Enrollment Form, this Agreement, any amendments to it
and the appropriate premium rate,
B. Premium Rate. The Group, or in the case of individual
or group canversion contracts, the Subscriber, agrees to pay
KHP Central in advance, on a monthly basis, unless
otherwise agreed, the applicable premium rate as filed with
and eppro~red by the Commonwealth of Pennsylvania
C. Changes of Premium Rate. KHP Central. subject to
the approval of the Commonwealth of Pennsylvania, may
change the premium rates. In the event of such change, the
Group shall be notified in advance of the effective date cf
change. ,~ny notice will be considered given when delivered
to the Greup.
Termination of Group
(1) Subject to annual renewal by the Group and KHP
Central, this Agreement, as amended from time to time.
will remain in effect from year to year unless terminated
either hy the Group or KHP Central
(2) The Group or KHP Central may terminate th~s
Agreement upon thirty (30) days written notice of
termination given to the other party.
(3) This Agreement shall automatically terminate at
KHP Central's sole discretion if KHP Central does not
receive the periodic premium payment within thirty (30)
days following the due date
(4) In the event of terminat~oh of the Group, coverage
for Members of that Group will end as of the last day of
the period for which the last premium payment has been
received.
(5) Members of a d~scontinued Group may become
convere~on Members provided the Group does not
particiFate in or secure coverage under a health benefit
plan made available by some other organization and the
termination is not done with the anticipation of securing
health benefit coverage with another organization
E. Termination of Subscribers and Members In
addition tc terminating coverage under this Agreement for
the Group as a whole KHP Central n~ay terminate thru
.'9
Agreement as to an individual Subscriber or Member as
follows:
(1) upon thirty (30) days written notice of termination
for cause (such as fraudulent use of an identification
card) by KHP Central. However, KHP Central will not
terminate this Agreement because of a Member's
Medically Necessary utilization of Services covered
under this Agreement;
(2) if the Subscriber in obtaining coverage hereunder,
shall have acted fraudulently or misrepresented or failed
to disclose a material fact. In such case, KHP Central
may, as its option, terminate this Agreement in
accordance with paragraph (1) above. The Group or
Subscriber will forfeit any charges paid to the extent of
the liability incurred by KHP Central;
(3) if the Member is unable to maintain a satisfactory
physician-patient relationship (See Article IV, Section 7,
J);
(4) if the Group or Subscriber fails to cooperate on
coordination of benefits or subrogation issues;
(5) for misuse of the Member identification card.
F. Obligations on Termination. In the event of
termination by the Group or by KHP Central:
(1} KHP Central shall not be liable for any services
incurred by any Member in the name of KHP Central
beyond the period for which the premium rate shaft have
been paid, and KHP Central shall be entitled to
indemnification by either the Group or the Subscriber for
any expense paid by KHP Central under such
circumstances.
(2) When this Agreement is terminated, except for
termination by incorrect information or
misrepresentation, and a Member is receiving Inpatient
Services billed by a Hospital on the date of termination,
benefits will continue to be provided only to the date of
discharge or expiration of eligible benefit days,
whichever is earlier.
G. Reinstatement. Any individual Member whose
membership shall have been terminated may be reinstated
at the discretion of KHP Central, and upon payment of any
retroactive premium payments and penalty due.
H. Other Changes in Statue. Applications for changes is
contract type or additions or deletions of eligible Dependents
shall be filed on Subscriber Data Change Forms supplied by
KHP Central and shall become effective and a part of this
Agreement upon acceptance by KHP Central.
30
I. Erroneous Payments. If KHP Central shall pay for any
excluded Services or supplies through inadvertence or error,
the Group or Member shall reimburse KHP Central for such
payments.
- j.
(1) The Subscriber who becomes ineligible for
coverage under this Agreement because of termination
of employment under his Group and who is not eligible
to become enrolled under any other group health benefit
plan, may apply within thirty (30) days after such
termination of employment to continue coverage under
an Agreement of the type for which he is then eligible,
For Members currently enrolled under a family contract,
this conversion privilege is a~so available to the surviving
Dependents in the event of the Subscriber's death, to a
spouee when divorced from the Subscriber, and to a
child who ceases to be an eligible Dependent due to
attaining the maximum age of eligibility. This conversion
privilege is not available to Members who have been
terminated for cause by KHP Central (See Article IV,
Section 7, E.), or for Members who have failed to apply
for conversion within the thirty (30) day period. The
terms of conversion coverage may be different than the
terms herein.
(2) If the Member becomes eligible for Medicare Part
A or Part B, the Member shall have the right at that time
to convert to such programs as may then be available to
provide coverage in conjunction with governmental
programs.
(3) If a Member enrolled in KHP Central through a
Group voluntarily elects to terminate his coverage with
KHP Central while remaining eligible for Group
coverage, the Member shall not be eligible for
conversion to such non-Group programs as KHP Central
may have available.
K. Continuation of Coverage. Federal law ("COBRA")
requires that under certain circumstances the Group offer to
the Subscriber and/or Dependents of the Subscriber
("Qualified Beneficiaries") the option of continuing coverage
under the Group's contract with KHP Central when such
coverage would otherwise terminate. The circumstances
under which this option is to be extended to the Qualified
Beneficiaries include: (a) termination of the Subscriber's
employment, either voluntarily or involuntarily; (b) the death
of the Subscriber; (c) divorce or legal separation of the
Subscriber; (d) Dependent children reaching otherwise
applicable age limits under this Agreement; and (e)
Subscriber becoming eligible for Medicare benefits.
Such Qualified Beneficiaries may obtain the same coverage
as the Subscriber is entitled to, for a period of three years
following tfieevent in question. Inthe caseofterminafion of
employment, the applicable period is eighteen months. The
3]
Beneficiary must pay the applicable premium for this
coverage.
Further, the Beneficiary may, within one hundred eighty
(180) days prior to the expiration of continued coverage
under COBRA, apply for conversion coverage under the
type of individual conversion Agreement for which he is then
eligible. Conversion to such an Agreement shall be
governed by the terms of the Subscriber Agreement which
provides continued coverage under COBRA.
Since provision of continued coverage under COBRA is the
Group's responsibility, Subscribers or Dependents who may
be eligible for such continued coverage should contact their
Group's representative for more information.
8 MISCELLANEOUS.
A. Notice of Claim. If submission of a claim is required to
receive Benefits under this Agreement, such claim shall be
allowed only if notice of claim is made to KHP Central within
sixty (60) days from the date on which covered expenses
were first incurred, unless it shall be shown not to have been
reasonably possible to give notice within the time limit, and
that notice was furnished as soon as was reasonabty
possible. However, Benefits shall not be allowed if notice of
claim is made beyond one year from the date on which
expenses were incurred,
B. Changing Primary Care Physician. If a Member
wishes to transfer from one Primary Care Physician to
another Primary Care Physician, the Member must submit a
written request for transfer to KHP Central. This request for
transfer shall become effective thirty (30) days after the end
of the month in which the request is submitted.
(1) Transfer of a Member to another Primary Care
Physician may be required if KHP Central determines
the Member-Primary Care Physician relationship is
unsatisfactory.
(2) If the Member's Primary Care Physician
terminates his relationship with KHP Central, the
Member must select another Primary Care Physician.
KHP Centrat will assist the Member in the selection of
another Primary Care Physician. If Member does not
select another Primary Care Physician, KHP Central
may assign the Member to a new Primary Care
Physician
C. Interpretation of Agreement. The laws of the
Commonwealth of Pennsylvania sha~l be applied to
interpretations of this Agreement Where applicable, the
~nterpretation of this Agreement shall be guided by the direct
service nature of KHP Central's operations as opposed to ~-
fee-for-service indemnity
D. Gender. The use of any gender herein shall be deemed
to include the other gender, and, whenever appropriate, the
use of the singular herein shall be deemed to include the
plural (and vice versa).
E. Modification. By this Agreement, the Group makes
KHP Central coverage available to Members who are
eligible under Section I of this Article However, this
Agreement shall be subject to amendment, modification.
and termination in accordance with any provision hereof or
by mutual agreement beb,veen KHP Central and Group
without the consent of concurrence of the Members By
electing KHP Central or accepting KHP Central Benefits, all
Members legally capable of contracting, and the lega~
represental:ives of all Members incapable of contracting
agree to all terms, conditions, and provisions hereof
F. Clerical Error. Clerical error, whether of the Group or
KHP Central, in keeping any record pertaining to the
coverage hereunder, will not invalidate coverage otherwise
validly in force or continue coverage otherwise validly
terminated
G. Policies and Procedures. KHP Central may acoDt
reasonable policies, procedures, rules and interpretations to
promote the orderly and efficient administration of th~s
Agreement, with which Members shall comply
Schedule of Copaymenta
The copayment listed below is the amount that you, the
Member, are required to pay in connection with the services
below. These services are defined in your KHP Central
Subscriber Agreement.
Outpatient mental health care: $25/visit*
*Your KHP Central benefits cover a maximum of
20 visits in a calendar year.
Outpatient Services for alcohol abuse:
1. First course of treatment: No copayment
Second and additional course of treatment:
Full session: $25/visit
Partial session: $15/visit
Emergency Room: $25/Visit
This copayment is waived if Member is admitted to the
hospital at the time of the emergency room visit.
If the Member is referred to the emergency mom by the
primary care physician or KHP Central and the service could
have been provided in the primary care physician's office,
then the emergency room copayment is limited to the
amount of the copayment for a primary care physician office
visit, if any.
After Hours Primary Care Physician Office Visit: $10/Visit
Infertility: 50% of the cost of treatment subject to a Benefit
Maximum of $2,500.
34
PENNSTATE
~ Milton S. Hershey Medical Center
College of Medicine ne Penn state Shock Traunm Center
Trauma Pro.am Mldicul Director
Robert A. ChenT, MD, FAC5
Sam L Scrvic~ BSN,CEN
Penn State Miltos S. He.hey M~dical Center
Penn S~ Collegc of Medicine
Mail Code: H0~
500 University Drive, P.O. Box 8~0
l-le~hey, PA 17033-08~0
Tel: (717) 531-~066
Fax: (717) 5314)3;21
Chairman
Department of'Sur~xy
V~rfley W. Souba, MD
Adult Trauma Surgeons
RobeR Cooney, MD
Jam~s Kas, MD
J. Stanley Smith, Ir.. MD
M~dicul Director
pediatric Traunm Pro,ram
Robert £. Cilley, MD
Pediatric Trauma Surgeon
Pe~z~ Dillon, MD
Andros Meier, MD
Pediah-ic Tram~ Coordlaator
Susan E. Rzucidlo, MSN, RN
Trauma Case ~ent
Rita Bani,, BSN. CEN
Rena Shelly. RN, BSN
Beverly Shirk. BSN. CCRN
Tcacy Siaopoli, RNC
Bounle Wilson, BSN. CCRN
Trauma Re~str.ars
Teresa Longcnecker
K..ristine Lucabaugh
Sharon Marcantino
Thursday, February 06, 2003
' Cumberland Valley High Sdhool
Samantha Miller sustained traumatic injuries on January 26, 2003 and was
admitted to the Penn State Children's Hospital.
She sustained Right claVicle and scapula fractures, multiple cervical,
thoracic and lumbar spinal fractures, right aeetabular fracture and sacral
fracture, liver and spleale lacerations. As a result of these injuries and
medical treamaent, she has the following a~etiVity restrietinns:
· Non weight-bearing Right upper extremity
· Non weight-bearing Right lower extremity
· Stand and pivot transfers Left lower extremity
· Torso rigid cast and Aspen Cervical collar on at all times
She requires homebound instmction'at tW.s time for a duration of 12 weeks
minimum, to commence after discharge fi:om inpatient hospitalization.*
Thank you for your attention to this matter. I am available at (717) 531-
7161 for any additional questions.
Beverly Shirk, RN BSN CCRN - Pediatric Trauma Case Manager
EXHIBIT "G"
II state
6345 FLANIf DRIVE SUITE 1000
HARRISBURG PA 1711~ *
PHONE NUMBER: 71%540-7500
OFFICE HOURS: MONDAY-FRIDAY 8:00-~;-.30
You're in good hands.
March 2~, 2003
RICHARD MOFFITF
2201 N 2ND ST
}~RRISBURG PA 17010
Allstate Indemnity Company
Cla/m N~ber: 1554556561 B19
Our Insured: PATRICIA COIl
Date of Loss: January 26~ 2003
RE: Samatha Miller
Dear Mr. Maffett:
I am in receipt of your letters dated March 18, 2003 addressed to Heather Bean
and Pat Hickey. Please be advised that I have assu~ed the handl±ng of these
files.
Claim number 155~556561 refers to the pr~ary liability policy and claim
number 1554555480 refers to the excess liability policy. Kindly direct all
records etc. to the primary policy.
Please be advised that the policy limits under t]~e primary policy are
$15,000/$30s000 and the limits ander the excess policy are $100~000/$300,000.
?ATRIClA A. HOFFMAN
Allstate Indemnity Company
sM06/0/01/1
RECEIVED MAR 2 5 2D03
EXHIBIT "H"
MARKET CLAIM OFFICE
6345 FLANK DRIVE S~glTE 1000
HARRISBURG PA 17112
PHONE NUMBER: 717-.540-7500
OFFICE HOURS: MONDAY-FRIDAY 8:00-5'.30
AIIstate.
You're in good hands.
September 23, 2003
RICHARD MOFFITT
2201 N 2ND ST
HARRISBURG PA 17010
Allstate Inde~ity Company
Claim Number: 1554556561 B19
Our Insured: PATRICIA COIA
Date of Loss: January 26, 2003
RE: Samantha Miller
Dear Mr. Moffitt:
Please be advised that ~ am prepared to extend an offer of our policy limits
under both the primary and the excess policy. I have enclosed a copy of
various structured settlement proposals for your client's review. As I am
sure you are aware this tax exempt option may well be in your client's best
interest.
Please contact me once you have had the opportunLty to meet with your clients.
PATRICIA A. HOFFMAN
Allstate Indemnity Company
SM06/0/01/1
01 Enclosure
G52-2
EXHIBIT
03/18/04 T~U 10:49 FAX 6108345442
RINGLER ASSOC
RINOLER ASSOCIATES
(610) 834-5553
(800) 869-9450
Fax (610) 834-5442 or (610) 834,8266
Via Facsimile
(717) 233-2342
002
March 18, 2004
Richard Moffitt
Attorney at Law
2201 N. 2nd Street
Harrisburg, PA 17110
Samantha Miller
File: #1554556561 and 1554555480
Dear Mr. Moffitt:
Enclosed is the updated structured settlement proposal in regarqs to Samantha's claim. I will
lock-in th/s quote and wiI1 prepare the Settlement Agreement and Release,
Please feel free to call if you have any questions or if we can be of further assistance.
Sincerely,
RINGLER ASSOCIATES
MPM.'jad
Enclosures
OFFIC'~ COURT AT WALTON POINT · 490 NORRISTOWN ROAD * SUITE 251 o BLUE BELL, PA 19422
MAILING ADDRESS: P.O. BOX 1252 · BLUE BELL, PA 19422
www. RinglerAssoctates,com
Ha~d~ ~o~[Mu, ~t ~ ~ ~, ~ Hilb (~),,~ M~ (NJ), Minr~p~ Mo~i~m~ ~), New ~le~, New y~,
EXHZBI~ J
03/18/04 THU 10:40 FAX 6108345442 RINGLER ASSOC ~003
INDIVIDUALLY DESIGNED SETTLEMENT
NAME: Samantha Miller FBMALB:
8/1/1986
TAX-FREE GUARANTEE
C~sh:
Guaranteed Lump Sums:
$10,000 at a§e 20 (8/1/06)
$10,000 at age 22 (8/1/08)
$15,000 at age 24 (8/1/10)
$20,000 at age 26 (8/1/12)
$24,125 at age 28 (8/1/14)
$30,000 at age 30 (8/1/16)
Total Cost: $115~000
38,333
109~125
$147,458
** This proposal expires on 3/25/04 or the date of a rate change, if earlier. **This is an
illustration, not a contract. Should it contain any clerical errors, we reserve the right to correct
ERIE INSURANCE EXCHANGE
E PIONEER FAMILY AUTO POLICY
AMENDED DECLARATIONS 05 * * EFFECTIVE 01/21/03
ATTACH T~IS TO YOUR POLICY.
REASON FOR AMENDMENT - COMP AND/OR COLLISION DEn AMENDED
AA7507 SHINER INSURANCE AGY PC 10/25/02 TO 10/25/03 Q10 2508246 H
I.,,lll,.lll,.,,,,ll,,ll,l,,I,,I,l,,.,ll,,l{,hl,.ll,,,ll,,I
JAMES L MILLER & AS LISTED BELON
STEPHANIE L MILLER
296 OLD STONEHOUSE RD
CARLISLE PA 17013-8513
AGENT - SHINER INSURANCE AGY PC 1001 S. MARKET STREET
SUITE C
AGENT PHONE - (717) 766-1200 MECHANICSBURG PA 17055 6748
ITEM 4. AUTOS COVERED
AUTO YR MAKE VIN ST TER Siq4 RATING CLASS DDP
~ 02 TOYO SEQUOIALTD 5TDBT48A92S137460 PA 4F P A2BL-M FM40
88 FORD PU F150 2WD 1FTDF15YOJNB14640 PA 4F A1AL-M MM45
ITEM 5. INSURANCE IS PROVIDED WHERE A PREMIUM. OR INCL, IS SHOWN FOR THE
COVERAGE. COVERAGES, LIMITS AND ANNUAL PREMIUMS ARE AS FOLLOWS-
%1 %2
*****GOOD DRIVER RATES APPLY*****
--- THE FULL TORT OPTION APPLIES TO ALL PRIVATE PASSENGER VEHICLES. ---
LIABILITY PROTECTION- --.
BODILY INJURy ~lO~/gmR~ON~$300M/ACC
-PROPERTY DAMAG~iODM/ACC
FIRST PARTY BENEFIT.~--~ MEDICAL EXPENSE<.%l/IH~
INCOME LOSSSIM/N0~H, $15MMAXIMUM
ACCIDENTAL DEATH SSM '
FUNERAL BENEFIT S2.5M
UNINSURED MOTORISTS COVERAGE-
ROD INJ S100M/~ERSON $300M/ACC-STACKED
UNDERINS 0 R COVE GE-
ROD IN~$30oMR~AcC-STACKED
PHYSICAL COWRAGBS-
CO REHBNSIVE - 55o0 DED
COLLISION -SlM nED
OPTIONAL COVERAGES-
ROAD SERVICE
TOTAL ANNUAL PREMIUM FOR BACH AUTO
TOTAL ANNUAL POLICY PREMIUM
PREMIUM REDUCTION DUE TO THIS CHANGE
86 80
86 82
41 41
2L3 13
2 2
2 2
:L5 15
79 79
114
22L3
655 314
$ 9159
$ 135CR
ITEM 6. APPLICABLE PoLIcY, ENDORSEMENTS. EXCEPTIONS TO DECLARATIONS
ALL AUTOS - FAP 04~97, UF2106 05/01, AFPN01 10/98, AFPA03 10/02.
AUTO I - AFPU01 04Z99.
AUTO 2 - AFPU01 04~99.
ITEMS
ANTI-THEFT DISCOUNT APPLIES-ALARM AUTO'I
MULTI POLICY DISCOUNT APPLIES - AMOUNT OF DISCOUNT IS $ 40
PASSIVE RESTRAINT DISCOUNT APPLIES - DUAL AIRBAGS AUTO 1
ANTI-LOCK BRAKE DISCOUNT APPLIED AUTO 1
EXPLANATION OF ADULT &/OR YOUTHFUL DRIVER RATING CLASS
AUTO 1-TO WORK 11-14 MILES ONE WAY, 8,501 OR MORE MILES ANNUALLY
FEMALE. MARRIED, AGE 40-66
AUTO 2-PLEASURE USE. 8.501 OR MORE MILES ANNUALLY
MALE, MARRIED, AGE 65-69
MISCELLANEOUS INFORMATION EXHIBIT "K"
ITEM 7. EACH AUTO WE INSURE WILL BE PRINCIPALLY GARAGED AT THE ADDRESS SHOWN
IN ITEM 1, UNLESS ANOTHER ADDRESS IS SHOWN BELOW.
ITEM 9. UNLESS A CO-OWNER OR LIENHOLDER IS LISTED BELOW, THE NAMED INSURED
IS THE SOLE OWNER OF EACH AUTO WE INSURE.
LIENHOLDER FOR AUTO 1
TOYOTA MOTOR CREDIT CORP
2 WALNUT GROVE DR 310
HORSRAM PA 19044-4295
DRIVER
1 JAMES L MILLER
2 STEPHANIE L MILLER
ST LICENSE NUMBER
PA 17122748
PA 19440843
BIRTM DATE
YOUR COLLISION COVERAGE AND DEDUCTIBLE APPLY TO PRIVATE PASSENGER
AUTOS YOU OR A RESIDENT RELATIVE RENT FOR 45 DAYS OR LESS. THIS IS
SUBJECT TO LIMITS, TERMS AND CONDITIONS IN THE POLICY.
Q10 2508244
October 17, 2003
KERRY J. Rr1'CHEY, CPCU, AIC
Claims M~ger
ERIE INSURANCE GROUP
Branch Office · 4901 Louise Dr. · Rossmoyne Business CenTer · P.O. Box 2013 · Mechanicsburg, PA 17055~0710
(7~7) 795-8200 · Toll Free 1-800-382-1304 , Fax (717) 795-2315 · www.efieinsu'ar~ce.com
Richard Maffett, Jr., Esquire
2201 North Second Street
Harrisburg, PA 17110
Re: Your Client:
Erie Claim No.:
Erie Insured:
Date of Loss:
James & Stephanie Miller
010170661624
Samatha Miller
January 26, 2003
Dear Mr. Maffett:
As per our conversation, this will confirm that Erie Insurance is offering the $200,000.00 Underinsured
Motorist Coverage limits as final settlement of Ms. Miller's Claka. As you are aware, th& settlement is
contingent upon completion of court approval. Also, I would appreciate it if you would discuss the
possibility of the Miller's structuring a portion of the settlement.
Thank you for your assistance.
Sincerely,
Claims Representative
(717) 795-2311
EXHIBIT "L"
The ERIE Is Above Ail In sERvIcF-~ Since 1925
JAMES L. MILLER, Parent and
Natural Guardian of SAMANTHA
JO MILLER, a Minor,
Petitioner
v
JORDAN L. BRANDT, Re spondent
IN THE CO~T OF CO~ON PLEAS
CUMBERLAND COU1TTY, PENNSYLVANIA
NO. 04-14713
CIVIL ACTION - LAW
PETITION ~RAPPROVAL OF
COMPROMISE SETTLEMENT INVOLVING
A MINOR
AFFIDAVIT
I, STEPHANIE L. MILLER, an adult individual residing at 296
Old Stonehouse Road, Carlisle, PA. 17013, hereby aver the
following:
1. I am the natural mother of SAMANTHA JO MILLER, a minor,
age seventeen (17), born August 1, 1986.
2. JAMES L. MILLER, Petitioner in the aforesaid matter, is
my husband, and natural father of SAMANTHA JO MILLER, the minor.
3. SAMANTHA JO MILLER, the minor, resides with my husband
Petitioner JAMES L. MILLER and me, at 296 Old Stonehouse Road,
Carlisle, Cumberland County, PA. 17013. We have sole custody of
SAMANTHA JO MILLER.
4. I have carefully read and reviewed the foregoing
Petition For Approval of Minor's Settlement and believe it to be
true and correct.
5. I believe the proposed settlement and compromise of my
minor daughter, SAMANTHA JO MILLER'S claim against JORDAN L.
BRANDT and Allstate Insurance Company, in the amount of
EXHIBIT M
$115,000.00, is in her best interests; and., I desire that the
proposed settlement be accepted and approved.
6. I also agree with, and approve of, the proposed
distribution contained in the Petition.
I verify the averments set forth in the foregoing Affidavit
are true and correct to the best of my knowledge, information,
and belief, and understand that false statements herein are made
Pa.C.S.A. Section 4904, relating
subject to the penalties of 18
to unsworn falsifications.
Dated: 03/24/04
Respectfully submitted,
EXHIBIT
JAMES L. MILLER, Parent and
Natural ~uardian of SAMARTHA
JO MILLER, a Minor,
Petitioner
v
ERIE INSURANCE COMPANY, INC.,
ResDondent
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 04-14713
CIVIL ACTION - LAW
PETITION FOR APPROVAL OF
COMPROMISE SETTLEMENT INVOLVING
A MINOR
I, STEPHANIE L.
Old Stonehouse Road,
following:
1. I am the natural mother of SAMANTHA JO MILLER,
age seventeen (17), born August 1, 1986.
AFFIDAVIT
MILLER, an adult individual residing at 296
Carlisle, PA. 17013, hereby aver the
a minor,
2. JAMES L. MILLER, Petitioner in the aforesaid matter, is
my husband, and natural father of SAMANTHA JO MILLER, the minor.
3. SAMANTHA JO MILLER, the minor, resides with my husband
Petitioner JAMES L. MILLER and me, at 296 Old Stonehouse Road,
Carlisle, Cumberland County, PA. 17013. We have sole custody of
SAMANTHA JO MILLER.
4. I have carefully read and reviewed the foregoing
Petition For Approval of Minor's Settlement and believe it to be
true and correct.
5. I believe the proposed settlement and compromise of my
minor daughter, SAMANTHA JO MILLER'S claim against Erie Insurance
Company, in the amount of $200,000.00, is in her best interests;
E]~IIBIT M
and, I desire that the proposed settlement be accepted and
approved.
6. I also agree with, and approve of, the proposed
distribution contained in the Petition.
I verify the averments set forth in the foregoing Affidavit
are true and correct to the best of my knowledge, information,
and belief, and understand that false statements herein are made
Pa.C.S.A. Section 4904, relating
subject to the penalties of 18
to unsworn falsifications.
Dated: 03/24/04
Respectfully submitted,
S~EPH~N:CE L. MILLER ~
EXHIBIT M
RICHARD F. MAFFETT, JR.
ATTORNEY-AT-LAw
2201 North Second Street
Harrisbur§, Pennsylvania 17110
FAX (717} 233-234,2
PERSONAL INoo~
POWER OF ATTORNEY AND CONTINGENT :FEE AGREEMENT
KNOW ALL ~ BY THESE PRESENTS, that I/we, JAM~S L. MILLER and
STEP~NIH L. MIT.?.~, PA~F-~TS k~'r~' O~IAN OF SAMANTHA JO MILLER, A
MINOR, do hereby retain RICHARD F. MAFFETT, JR., a member of the Bar of
the Supreme Court of Pennsylvania, as my/our attorney to negotiate for
an adjustment, or to institute for me/us in my/our name any legal
actions or proceedings that in his judgment are necessary, in connection
with my/our claim for damage against JORDAN BRANDT, ALLSTATE INSURANCE
COMPANY, ERIE INSU~_~wCE COMPANY, T~Y aLL~I, KEITH BRAMLETT, EMPIRE
F!~ AND MARINE, PennDOT0 or anyone else as a result of injuries or
damage sustained by SAMANTHA JO MILLER on or ~oUt the 26TH da~ of
JANUARY , 2003.
KNOW, THEREFORE, in consideration of the.services to be so rendered
by my/our said attorney, I/we hereby covenant, promise and agree to pay
my/our said attorney for his professionalservices rendered TWENTY-FIVE
(25%) PERCENT of whatever sum is recovered as a result of settlement, or
of the verdict in the event trial is held.
I/we also agree to pay any necessary expenses, i.e., court costs,
stenographer and transcription fees, records fees, e~ert witness,
investigation costs, whether or not there is a recovery, with a cost
advance of $ -0-
This agreement is for representation through trial only and does
not include an appeal. In the event an appeal is necessary, additional
fee arrangements must be made.
AND NOW, this _~ day of ~--~. , 2003, the above Contingent
Fee Agreement and Power of Attorney has been read, approved and
understood by me/us and the receipt of a copy 'thereof acknowledged. The
terms set forth are agreeable.
WITNESS
WITNESS
J~s L. ]~xller, Parent & Guardian
of Samantha Jo Miller, a Minor
Stephanie L. Mmller, Parenn
Guardian of Samantha Jo Miller, a
Minor
EXHIBIT "N"
PENNbTATE
~ ~ nc MiltOn S. Hershe~
RE:Account #
Patient Name:
Enclosed are the copies of the bills you requested. Based upon your request please remit $15.00 for copies of hills.
Checks should be made payable to:
Hershey Medical Center
P.O. Box 853
Hershey Pa 17033
Arm: Cindy Fra_m:z
Our Federal Tax LD. #'s are: Physician 25 185 7035, Hospital 25 185 4772
If the patient was ~li~ble for Medical Assistemce Beuefit.% copies of bills will be sent to and reviewed by the Mediml
Assistmme R~cov~ry Board.
Dep~'tu~mt oft:~blic W*lfare ...-
Bm ofFi~-~cial Opea'z~oas ...
TPL section Casually Unit
P.O. Box 8486
l:-I,m'risburg PA 17105.
Plea.s, ,o-ta~'t The medicul Asistm~e Reyvea'y Board directly 717-772-6623..
H~r~hey Meclic. aI"C'~mr
Patient Fir~ncial Services
717-531-5984
EXHIBIT "0"
v .r- 2 2003
REOORDEX AC ~Q~JI~ITION CORP
SOURCECOR~,~EALTHSERVE
17 LEE BLVD, STE D
Malvern PA 19355
Phone: (610)640-0600
Fax : ()-
Invoice No. : 17BQ-54362
Invoice Date : 09/29/2003
Sales Code : CT8227
Class / Type : LAW / LAW
Price Class : STD
EIN : 51-0370082
RICHARD F MAFFETT
2201 N2ND ST
HARRISBURG, PA 17110
Patient:
Hospital:
RequestNo:
SAMANTHAMILLER
HERSHEY MEDICAL CENTER
170698 Request Date:
09/16/2003
Birth Date: 08/01/1986
Reference %: SS1657800992
CODE SERVICE RENDERED
5 BASIC CHARGE
10 COPY CHARGE
40 ARCHIVAL FEE
TERMS: DUE IMMEDIATELY
SUMMARY OF CHARGES FOR MEDICAL RECORDS
UNIT AM'T QTY.
TAX EXT. AM'T
12.5600 1 N
1.1100 16 N
4.0000 1 N
POSTAGE:
TAX:
LESS: PAID IN ADVANCE:
12.56
17.76
4.00
1.06
0.00
0.00
35~38
PLEASE SEND PAYMENT TO RECORDEX ACQUISITION CORP
PLEASE INCLUDE YOUR INVOICE NUMBER ON YOUR REMITTANCE.
PLEASE RETURN A COPY OF THE INVOICE WITH YOUR REMITTANCE.
RECEIVEO OCT - 2 2003
~ Thc Mihon ~,. ,h~rsne.;'
Enclosed are the copies of the bills you requested. Based upon your request please rem/t $15.00 for copies of bills.
Chee~ should be made payable to:
Hershey Medical Center
P.O. Box 853
Hershey Pa 170.33
Arm: Cindy Frantz
Our Federal Tax I.D. #'s are: Physician 25 185 7035, Hospital 25 185 4772
If the patient warn eligible for Medical Assistance Benefits, copies of b/lis will be sent to and reviewed by the Medical
Assistance Recovery Board.
Depm'tment of Public Welfare ' --
Bm~au ofFinaucia~ Opmfions
TPL section Casualty
P.O. Box 8486
Yrlarr'isburg pA 17105.
Please contact The medical ~istance Recovery Board d/reedy 717-772-6623..
Patient Fimm=ial Services
717-531-5984
APR - 281
~OUR~CORP. HEALTHSET?VE
Fax : 0 -
INVOICE
2201
VISA / MASTERCARD ACCEPTF_X)
ORIGINAL
03/l~/Zuoq 13:47 FAX 717 728 1502 RINGLER ASSOCIATES ~001
RINGLER ASSOCIATES, INC.
FACSIMILE TRANSMITTAL SHEET
TO: RICHARD MAFFETT, ESQ. FROM: JOHN W. CAMERON
COMPANY: DATE: 3-18-2004
FAX NUMBER: 717-233-2342
CC: DOUG KOCHER
TOTAL NO. OF PAGES INCLUDING COVER:
2
RE: SAMA~'~{A MILLER.
FAX PHONE: 717-774-0233
CLAIMS NUMBER: 010170661624
[] URGENT [] FOR REVIEW [] PLEASE COMMENT [] PLEASE REPLY [] PLEASE RECYCLE
NOTES/COMMENTS;
Dear Mr, Maffett:
This will confirm our conversation on March 18, 2004 r~garcling your client,
Samatha Miller. Attached is the structured settlement proposal you requested. If it Es
acceptable to you and your client, please call me and I will lock it in and process the
necessary paperwork, to include preparation of the release.
The enclosed figures are for illustrative purposes ordy and should not be
construed as a contract. All figures are subject to approval by the life insurance carrier
prior to contract issuance. If you have any questions rega~ting this proposal, please call
so we can discuss them.
John W. Cameron
4902 CARLISLE PIKE + PMB 395 ~ MECHANICSBURG, PA 17050
PHONE: 717-728-1500 * FAX: 717-728-l$02
E~HIBIT P
03/18/2U04 13;47 FA~ 717 728 1602 RINGLER ASSOCIATES ~002
O0
~NGL.FJ~ ASSOCIATES
John W, Cameron
jcameron@ringlerassociates,com
(717) 728-1500
(800) S15-5033
(717) 728-1502 (FAX)
March 18, 2004
Individually Designed Settlement
Samatha Miller
D/O/B 8/1/88
BENEFIT
COST GUARANTEED
YIELD
Guaranteed Lump Sums
Tax-frae payments:
$ 10,500 on 08/01/06 (age 20)
$ 10,500 on 08/01/08 (age 22)
$ 10,500 on 08/01/10 (age 24)
$ 10,500 on 08101112 (age 26)
$ 10,500 on 08/01/14 (age 28)
$130,000 on 08/01/16 (age 30)
9,763 10,500
9,158 10,500
8,590 10,500
8,058 10,500
7,559 10,500
87,784 130,000
$130,912 $182,500
4902 CARl TSI F P[KE, PMB 395, MECHANICS;BURG, PA 17050-3079
www.dnglermidam.corn
VERIFICATION
I, JAMES L. MILLER, Parent and Natural Guardian of Samantha
Jo Miller, have read the foregoing Petition for Approval of
Minor's Settlement and hereby affirm that it is true and correct
to the best of my knowledge, or information and belief. This
verification and statement is made subject to the penalties of 18
Pa. C.S.A. §4904 relating to unsworn falsification to
authorities; I verify that all statements made in the foregoing
are true and correct and that false statements may subject me to
the penalties of 18 Pa. C.S.A. §4904.
Dated: 03/24/04
MILLER, Parent and
~uardian of
Samantha Jo Miller
JAMES L. MILLER, Parent an~
Natural Guardian of SAMANTHA
JO MILLER, a Minor·
Petitioner
v
*.TOI~.DA,N L · BE~'~· Defendant
IN THE COURT OF CO~ON PLEAS
CUMBERLAND COUITTY, PENNSYLVANIA
NO. 04-1473
CIVIL ACTION - LAW
AND NOW, this~
consideration of the Petition For
it is hereby ORDEHED AND DECREED that:
PETITION FOR A~PROVAL OF
COMPROMISE SETTLEMENT INVOLVING
A MINOR
o
__ day of~~__, 2004, upon
' A~oval of Minor's Settlement,
I. DEFENDANT JORDAN L. BI~%NDTANDALLSTATE INSURANCE COMPANY
Petitioner is authorized to enter into a settlement with
Defendant, JORDAN L. BRANDT, and her insurance company, Allstate
Insurance Company, in the gross sum of $11.5,000.00. Petitioner
is authorized to sign a release and to mark the matter settled,
discontinued and ended as to the above Defendant.
These settlement proceeds shall be distributed as follows:
$28,750.00 to Richard F. Maffett, Jr., Esquire, in
payment of attorneys fees;
$9,583.00 to JAMES L. MILLER, as Parent and Natural
Guardian of SAMANTHA JO MILLER, a minor, to be deposited
into a restricted, federally insured account marked UNo
withdrawals prior to age eighteen (18) without prior court
approval.
$76,667.00 to Allstate Life Insurance Company to fund a
structured settlement by the purchase of an Annuity Contract
whereby guaranteed payments shall be made to SAMANTHA JO
MILLER.
II. ERIE INSURANCE GROUP
Petitioner is authorized to enter into a settlement of
underinsured motorist benefits for which the Minor, SAMANTHA JO
MILLER, is eligible pursuant to Petitioner's policy of automobile
insurance with Erie Insurance Group, in the gross sum of
$200,000.00. Petitioner is authorized to sign a release as to
Erie Insurance Group.
These settlement proceeds shall be distributed as follows:
$50,000.00 to Richard F. Maffett, Jr., Esquire, in
payment of attorneys fees:
$266.74 to Richard F. Maffett, Jr., Esquire, in
reimbursement of litigation costs;
$9,733.26 to Petitioner, JAMES L. MILLER, for payment
of medical bills;
$9,088.00 to Petitioner, JAMES L. MILLER, as Parent and
Natural Guardian of SAMANTHA JO MILLER, a minor, to be
deposited into a restricted, federally insured account
marked "No withdrawals prior to age eighteen (18) without
prior court approval.
$130,912.00 to Erie Life Insurance Company to fund a
structured settlement by the purchase of an Annuity Contract
whereby guaranteed payments shall be made to SAMANTHA JO
MILLER.
BY THE COURT: