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HomeMy WebLinkAbout04-2569IN RE: MICHAEL LONGENBERGER IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA No. CWIL TERM PETITION FOR APPROVAL OF MINOR PLAINTIFF'S COMPROMISE SETTLEMENT Pursuant to Pa. R.C.P. No. 2039, Marilyn Zemanik, as parent and natural guardian of Michael Longenberger, files this Petition for Court Approval of her son's settlement and in support avers as follows: 1. Petitioner, Marilyn Zemanik is an adult individual residing at 4 Country Club Place West, Camp Hill, Cumberland County, Pennsylvania 17011. 2. Petitioner is the parent and natural guardian of Minor PlaintiffMichael Longenberger who resides with her and who is 13~years old, having been bom on February 10, 1991. 3. Petitioner has sole legal and physical custody of Michael Longenberger as reflected in the Custody Order attached hereto as Exhibit "A" and incorporated herein by reference. 4. Minor PlaintiffMichael Lungenberger has selected Petitioner, as his parent and natural guardian, to represent his interests in this Petition. Document #300202, I 5. At all relevant times hereto, USAA was the homeowner's insurer for Michael and Lynn Placzek who reside at 219 Wood Street, Camp Hill, Cumberland County, Pennsylvania, 1701 I. 6. On October 6, 2002, Michael was visiting the Placzeks' son at the Placzeks' aforesaid home address. 7. During the visit to the home, Michael was playing soccer when he was bit on the left calf by the Placzeks' dog. A true and correct copy of the animal bite report for this incident is attached hereto as Exhibit "B" and incorporated herein by reference. 8. The Petitioner is claiming that Placzeks were liable for the dog attack based on theories of negligence and violations of the Pennsylvania Dog Law found at 3 P.S. § 459-101 et seq. 9. As a result of this dog attack, Petitioners made a claim to USAA who insures the Placzeks for this incident. 10. As a result of the dog bite, Michael was taken to Holy Spirit Hospital Emergency Room on October 6, 2002 where the physician reported that his left calf laceration appeared to be under some tension, he appeared to have a tear wound and 2-3 pmlcture wounds. l I. At the hospital, x-rays were ordered of Michael's leg to evaluate whether any foreign bodies were present, such as a tooth, and the x-rays were read as normal. 12. Michael was sutured at the emergency room and instructed to follow-up with his regular physician for re-evaluation and suture removal. A true and eorreet copy of the hospital records are attached hereto as Exhibit "C" and incorporated herein by reference. Document #300202,1 13. On October 18, 2002, Michael saw his regular family physician, David A. Long, M.D., who evaluated the wound and removed the sutures. Michael was told to wash the wound on a regular basis and discharged him from care with no restrictions. 14. On January 13, 2003, Michael returned to see Dr. Long regarding an unrelated injury but at that appointment he asked Dr. Long to evaluate the scar that had been sutured because of the dog bite because he was having some nmnbness and slight pain in that area. 15. During the January 13, 2003 appointment, Dr. Long noted that there was numbness directly over and proximal/distally to the incision within 3 millimeters. 16. On April 10, 2003, Michael returned to Dr. Long continuing to have numbness in that area of the left leg and upon examination the doctor noted that Michael had decreased sensation with pin prick in the wound and in fact it was total anesthesia. Dr. Long noted that "in an area about 10 centimeters in diameter around the wound he has an area of diminished sensation." Dr. Long further stated that "he can feel but it is not as sharp as it is on the other side." 17. Dr. Long's diagnosis on April 10, 2003 was "healing wound of the left posterior calf with periwound numbness." Dr. Long informed Michael's mother that he was not aware of any therapy that could bring the sensation back nor make any difference in the appearance of the wound. A tree and correct copy of Dr. Long's records are attached hereto as Exhibit "D" and incorporated herein by reference. 18. Michael has not received any further medical evaluation since April 10, 2003. 19. Michael's medical expenses for the treatment set forth above total $1,039.25. The medical bills have been paid by Gateway and they have asserted a lien in the amount of $300.34, which Petitioner will pay $142.45 in satisfaction of the lien, a/ter deduction of Document #$00202.1 Gateway's pro rata share of attorney fees and costs. A true and correct copy of the payout sheets and correspondence from Gateway are attached hereto as Exhibit "E' and incorporated herein by reference. 20. 21. Michael was not employed at the time of the bite and has no wage loss claim. As a result of the dog bite, Michael has a scar on his left leg, which will be permanent. A true and correct color reprint of a photograph of that scar taken on July 3, 2003 is attached hereto as Exhibit "F" and incorporated herein by reference. 22. On behalf of its insureds the Placzeks, USAA has agreed to pay $12,000.00 to Michael and his mother to resolve the liability claim against the Placzeks as a result of this dog bite. A true and correct copy of the letter offering the $12,000.00 is attached hereto as Exhibit "G" and incorporated herein by reference. 23. The Petitioner, after consultation with counsel, determined it is in the best interest of Michael to accept USAA's offer on behalf of its insured and seek Court approval of the same. 24. The Petitioner, after consultation with counsel, determined that it would also be in the best interest of Michael to allocate $8,500.00 of the settlement amount to a structured settlement account, where Michael would receive a lump sum payment of $10,468.00 at age 21, on February 10, 2012. The lump sum payment would be guaranteed and "tax-free" and payable to his estate or his designated beneficiary should he die before receiving all of the money. A true and correct copy of the annuity quote is attached hereto as Exhibit "H" and incorporated herein by reference. 25. The assignee or the entity to make the payment is USAA Life Insurance Company, which has been rated highly by accredited rating organizations. A true and correct Document #$00202,1 copy of the documents on the financial health of the assignee are attached hereto as Exhibit 'T' and incorporated herein by reference. 26. The internal rate of return or interest rate for this structure is 2.7 %. 27. Out of the remaining $3,500.00, the sum of $157.00 will be given to Petitioner for the immediate benefit of Michael. 28. The remaining sum will be paid to counsel for Petitioner and Michael, who was retained to represent Michael on a contingent fee basis of 25% plus expenses, which fee is fair and reasonable for the time and effort expended on behalf of Michael. A copy of the Fee Agreement is attached hereto as Exhibit "J" and incorporated herein by reference. Counsel's attorney fee at 25% would be $3,000.00. Counsel has also incurred the following expense on behalf of Michael: Fil/ng Fees $ 55.50 Medical Records $ 55.45 Photocopies $ 51.09 Postage $ 24.81 Long Distance Phone Calls $ .70 Fax $ 9.00 Miscellaneous $ 4.00 TOTAL $200.55 29. Petitioner respectfully requests that this Honorable Court approve of the settlement with USAA and the Placzeks in the gross mount of $12,000.00, out of which Petitioner will receive directly for the immediate benefit of Michael the sum of $157.00, counsel will receive the sum of $3,200.55 and the remainder or $8,500.00 will be allocated to a structured settlement account. 30. The Petitioner's request for the balance to go into a structured settlement account is in accordance with Pa. R.C.P. No. 2039 and in particular No. 2039(b)(3). Document #300202.1 31. Upon approval, the Petitioner, Marilyn Zemanik, will sign the Settlement Agreement attached hereto as Exhibit "K" and incorporated herein by reference. 32. USAA, on behalf of its insureds, the Placzeks, concur with the filing of this Petition and also seek approval of the minor settlement under the terms set forth above. WHEREFORE, the Petitioner respectfully requests that this Honorable Court approve of the settlement and enter an Order distributing the funds as follows: (1) (2) (3) (4) To be paid to Marilyn Zemanik, parent and natural guardian of Michael Longenberger, the sum of $157.00 for the immediate benefit of Michael Longenberger; To be paid to Gateway, the sum of $142.45 in satisfaction of the medical lien; To be paid to Metzger Wickersham, P.C. for counsel fees and expenses - the sum of $3,200.55; and The balance of $8,500.00 to be placed in a structured settlement account, the money to be transferred by United Services Automobile Association (USAA) to the structured settlement account. The account will provide a guaranteed lump sum payment of $10,468.00 to Michael Longenberger at age 21 on February 10, 2012, or if he should die before the payment is made, to his Estate or such other persons or others as shall be designated in writing by him to the insurer or insurers' assignee. Dated: June 3, 2004 METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Petitioner Document #300202.1 Exhibit A MARILYN M. ZEMANIK, Plaintiff RODNEY A. LONGENBERGER, Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION ~ LAW : CUSTODY : NO.2354 CIVIL 1994 CUSTODY AND VISITATION AGREEMENT THIS AGREEMENT, made this~hay of ~, 1994, between Plaintiff, Marilyn M. Zeman~k~ (he~:einafter "Mother") and Defendant, Rodney A. L°ngenberger, (hereinafter "Father") concerns the custody and visitation of the children: Michael Longenberger, born February 10, 1991, and Nicole Longenberger, born October 9, 1989. WHEREAS, mother and father desire to enter into an agreement as to the custody of the children, Michael Longenberger and Nicole Longenberger, and to have this agreement made an Order of Court, mother and father agree to the following: 1. The mother shall have Sole legal and physical custody of the children subject to reasonable visitation by the father (when he is not incarcerated in prison). 2. The father shall have visitation at mother's house with at least twenty-four (24) hours notice. Such notice will not guarantee visitation if Mother has already made plans for or with the children. 3. The father shall not remove the children from mother's house during visits. 4. The father shall refrain from drinking alcohol and using illegal drugs in the presence of the children. .5. The father shall refrain from drinking alcohol and using illegal drugs during the six hours preceding all visitations of the children. 6. The father acknowledges that he has been informed that the Family Law Clinic only represents the mother in this matter and that the Family Law Clinic has not given him any legal advice other than to seek his own counsel. 7. The undersigned parties intend to be legally bound by the terms of this agreement. Certified Legal Intern THOMAS M. PLACE LINDA E. FISHER HARVEY A. FELDMAN Supervising Attorney Family Law Clinic 45 North Pitt Street Carlisle, PA 17013 717-243-2968 Date ~ //) [qqq Approved and entered as an Order of Court. Exhibit B HOLY SPIRIT ER Fax:717-972-4295 Oct 6 2002.22:10 -[ TH '~"'~ .............. C,rlis,¢,4" E;~s,pA.~o~h' 1'013-2~,35'r'¢' ' ' ~ ~ Fhon~: (71~_243-5~5% ~I~ ~ REPORT j L.I ~ ,J ~ ..~ ~ da/ P~ motl Da~¢ Repurt Received b)' DON Log No, , .... ~,~. ~. , ,, . - A. ~ .:~ , Exhibit C NA~1E: .ONGE~.~E~3E~ ,~IC~AEL A S~ ~: EHPLOYER: dNg HPLO'f'A D OCCUPA'F l Of 4: Meds PMH Checklist; None E~ MI [] HTN [] CAD [] CH~[] ASTHMA [] CANCER ~ STROKE[] NIDDM D Surgeries [] Allergies Latex Allergy Yes [] No~ ImmunJ~,/~ UTD [] Not UTD [] TetanusL~J~ LMP HOH ~ S~s ~¢ish: Ye~ No ~ Trse~t ~ ~dage lnfo oblai~by: EMT~ Medic[J List~ ~les~ Pati~~. DOse Me~ Do~ M~ Room: Advar~ced Directives Yes [] No/ Attached Yes [] NO/ Exposure to measles, chxn pox, TB? Yes [] No[] PAIN ~SESSMENT Locetlo. ([) Intensity Scale /j::7 /10 Adult/DC' Wong Baker [] Character: Ache [] Dull [] Sherp[] Pressure [] Throbbing [] Radiating [] Ou'ation (1~7 Frequency" What relieves Pein? Triage Notes: Dose Meds Unknown E3 Injury: Place Occurred: Home/WorkL~ Other~_ . SkinSkin Temp:C°l°r: WNLEf'M~ [] Cya~ot/c DWarmj~¢ Cool [] Location On 6C~; Distal Pulses' YeseS%' No [] ' ~'¢t~I~,~~,~.~¢~, Edema: Yes [] No ~ Holy 80irit Hospital Camp Hill, PA 17011 John R. Die~z ECU Nur~lr~l A~me~t CHART COPY IniU~l ~ & x-fl~, Or, ers: ] CMP J PTP [ 1Kn~ R L ] Thmmbo~ytic Laos ] Tox ,~een [ ] Urina Tox ~creen I TSHR ] Type&Croas __ # of un~ (0OR) Pye~gram IVP Ribs fl L T/~i~ [ ] [ ] EKG [ ] 02 Lea~. [ ] P~e~pirat<x'y Tx. Me~le~ne, I IV~a / Additional O~ders [ ] Obtain old room'cle [ ]Td for: Inlflats;_ Sfg~atm'e: RN,~4JA Inrdalm Signature: RN/MA Dictated: Half [ ] Completed [ ] CRITICAl. CARE: hrs. Dl~gno.lc Impreerdon: ~)C>D ~ (; l Holy sp~m Hoep~l Camp Hill, PA Physician O~'det' Sheet CHART COPY Ne uro..~A-- Ac. ut:y: L._./~ Inlllal Signature Initial T~me Notes ................... S~_A&T Time Notes ~arg~ 1~ by: ~/~ to:~ome ~numtng home ~ gOR ~che~ in~uc~ns given to: ~ed unde~bnd~g of d/c in~c~ Camp Hill, PA 17011 ~ ' - HSH ~DIOLOGY 1ST FLOOR 972 DATE; Oct 8 2002 LOCATION: ER1 HQSP SVC; ERr METHOD 0¢~ TRN~S: PATIENT; SC)(; SEC: MED EEC ~, AGE: 0H DATE: Allergies: Room #: 9000~ 305728 ltY Oct 8 20~2 8:48PM FERRARO. KATA~I~H~ - (7171 Totat # of FilmS: EXAM DATE: Oct 6 2002 1641 LEFT I.~O COMMENTS: Ox/Den: ~OSS FB ISola~Bon: READING TIME READ: REPORT DICTATED: Y N Holy Spirit Hospital I::~H~u, tm~t of Radiology and '~ In~ (7'1 ?) 763.2600 PATIENT: LONGENBERGER, MICHAEL A M~I~: 305728 8OC SEC: 999-*02-1091 ORD DR: KATARZYNA FERRARO PT TYPE: E DOB: 02/10/1991 LOCATION: ER1- DICTATION [;)ATE: Oct 6 2002 9:37P TRAN~3RIPTtON DATE: Oct 7 2002 8:55P ADM DATE: 10/06/2002 ARPJVAL DATE: 10/06Y,['002 HOOP S~RVICE: ER1 ***Final Report*** EXAMINATION: LEFT TIBIA AND FIBULA (2V) 73~90 - 10/66/2002 COMMENTS: INDICATION; Dog b/re. No bony or soft tissc~e abnormality is kJent~ed. No radioPaciue for~gn body is identified. CONCLUSION: Normal appearances. DICTATED BY: SIMON WESTACO'I-r M.D. / RJL DATE OF EXAM: 10/06F2002 SIGNED BY: DATEFI1ME: SIMON '¢~=_STACO3-1' M.D. Oct 82002 2:51P CONSENT TO MEDICAL TREATMENT I HEREBY CONSENT AND AUTHORIZE Holy Spirit Hospital, its a~mts, and ~mployess, to the ren~lering cf medical care, which may include routine diagnostic proced~es and~such mediCal treatmer~t as m? attendi~ or consulting phy~cian considers to :be necessary. I also ~der- stand it ia customary, absent emergency or extraordina~ circumstances, that no substantial procedures wilt be performed upon me uniass or until t have had an opportunliy.to discuss them with a physician o~ otha~ health care prOC~,slertal to my.saasf~ction, If I am a competent adult. I have the right to consent or refuse to consent. I under, tend that the practice of medicine and s~l~gery, is no~ an exact solaces and that diagno- sis and trestme~t m~y involve risks of injury or even death and acknowledge that no guarantee nas bee~ mede to me es to the results of any examination or treatment In this Hospital. t understand many of the physiC!ass on the s~ff of Holy ..~rit Hospital are not employees ~ agents of the Hospital, but rattier are Independent contractors who have been granted the privilege ef using these facilities for the care and treatment of their patients. Further, I realize this Hospital is a teaching Hospital and at ~he Hospital are haalth care personnel in trafafag who, unless expressly reqaested otherwise, may pa;rl~cipate or may be present during my care as part of their education, Stt[l or mof~o~ pictures and clOSed cffcult monitoring of patient care may also be used for educational purposes, unless I expressly request otherwise. I understand that in order to ensure s sate environment for patients, visitors and staff all property on the premises of Holy Split.>spiral is subject to reasonable search and/or seizure at any time without further notice. :~s RELEASE OF MEDICAL INFORMATION t authorize Ho~ Spirit Hospital to release to requesting health insurance carrier(s), their rapresentat~ve~ and ~.uditors, and any referring health care providers, such diagnostic and therapeutic information (including any ibformation retat~g to treatment for alcohot and eubetac~e abuse and/or treatment of psychiatric disorders, and/or_confidential HI¥ reiat~d infl~'rnafien, as may be.necessary for them to determine benefit anti* tlement; to process payment claims for health ca~e services provided during this hosp]talizetfon/trestment episode, and tor continuing care/treatment. A photocopy or ca.on copy of this authorization shall be considered as effective and valid as the original The undersigned also authorizes Medicare, when applicaat~e, to release to ~nother insurance carrier, upon their request, medical information needed to make payment upon that claim. [ understand and consent that the manufacturer of any implanta~le device inserted by my physician during the course of .~y..~brgef~r~;~.eclure may be provided with my identificalion Information, including social security number, as man~ated by Federal Law. I~i~ls INSURANCE ASSIGNMENT OF BENEFITS I authorize payment directly to t-~oiy Spirit Hospital and my treating physicians of alt benefits payable under my insurance policias.,I,..j~nd,,~/ae'~'and I am responsible to the Hospital and Physicians for all charges not covered by this assignment. I~ y ~ STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AND P~TIENT I request payment of Authorized Medicare benefits to me or on my behalf fur any services furnished me by or in I"t~y Spirit Hospital including physician services. I authorize any holder of medical and other information about me, to release 'to Medicare and its agencies any information needed to determine these benefits for related services. Initials MEDICAL ASSISTANCE RIEC~PtENT My signatures certifies that I received a service or items from Hoiy Spirit Hospltat and Dr. __ on the date listed below. I understand that payment for this service or item will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under akoplicable .Federal and State Laws. I understand that certain te~ts and procedures may not be reimbursed by Federal and State funds and that I may be responsible for non co¥~rad charges. Aiao~ I agree that if at the time of ~lrvtce, if I am n°t eligible f°r Medical Assistance' I will be resp°nsfbts f°r balances °wed to H°~Y Spirit H°spital' ~s /~"'-~ HOLY SPIRIT HOSPITAL, CAMP HILL, PA CONSENT FOR TP. EATMENT/ RELEASE OF INFORMATION 1NSUP~NCE ASSIGNMENT CHART COPY ADM. DATE: 10/06/2002 CHIEF COMPLAINT Dog bite. HISTORY OF PRESENT ILLNEff~ This 11 year-old malt presents to the Emergency Department with complaining of a dog bite whloh happened late this evenir~ at approximately 7:30 He reports that he was playing soccer and the dog bit his leg. Apparently, ~is is a friend's dog. They claim that the immunizations are up-to-date and that the dog will be observed for the next 2 weeks. He denies any other injuries or comp~ints, He claims he has ambulated on the leg, PAST MEDICAL HISTORY None, Left corneal injury, MEDICATIONS Ocuftox. ALLERGIES NKDA. VITAL SIGNS Temperature 98.3, pulse 85, respirato~j rate 18, bE)od I:m~sure 1:11/60. PHYSICAL E~I~MtNATION Vital Sig~ revlev~d on numa's not~. He's an alert, cooperative, 11 year-o~l, male who appears to be in no obvious respiratory distress. He's sitting comfortably on the bed. EXTREMITIES: Focused extremity examination reveals intact dlstat pulses, sensation and strength. He does have an approximately 1.5" laceration tothe posterior aspect of his ieff catf. This does appear to be under some tension. It appears to be a tear wound. He also has two to her puncture wounds noted. I did discuss risks and benefits of sewing these wounds and the risk of infection. Given that this is a dog bite, I do not feel that it is unreasonal:~e to sew this as tong as it is closely Obee~,~ed. We did do x-rays to evaluate for foreign body and this was negative for any tooth. The patient's wounds were copiously irrigated with normal saline, Thereafter, I did: probe the large wound end I did not visualize any foreign bodies. 1% lidocaine without epinephrine was used. Approximately 2 cc was infiltrate and thereafter a total of 6 suture were 1:~3ced. Five horizontaJ mattresses and one regular simple suture. The patient tolerab~d the procedure well. There were no complications. Puncture wounds were simply irrigated. Apparently, his immunization status was up-to-date so we did not administer this. PLAN Have him follow up with his regular, physician within the next 1-4 days for reevaluation. He shoutd have his sutures removed in 10 days. He should return seoner for any signs of infection which I did discuss at length with the family. DIAGNOSIS Dog bite 1.5 cm. laceration left calf and multil;~e puncture wounds left calf. HOLY sPIRIT I'tO~PITAL Camp Hilt, PA 17011 ~RGENCY ROOM REPORT Page t of 2 NAME: Longenberger, Michael A MR#: 305728 ROOM: ER1 DR.: KATARZYNA K FERRARO, MD COPY NAME: MRS: Longenberger, Michael A 305728 KFIgn DOC #: 279310 D: 10/06/2002 T: 10/12/2002 11:21 A 345465 CC~ KATARZYNA K FERRARO, MD HOLY 8talRIT ~$PITAL Camp Hill, PA 17011 EM~ERGENCY ROOM REPORT Page 2 of 2 NAME: Longenberger, Michael A MR#: 305728 ROOM: ER1 DR.: KATARZYNA K FER:RAP, O, MD COPY '~MERGENCY C~TEI~ UI~GI CgWrgR DISCHARGE INSTRiYC~NS HOLY SPIRIT HOSPITAL (717) 763-2316 - (717} 763-24~4 o /~tken[ Infon~la~n: Patient Informlflon ) Use cru~es: ( ) Az oeede~, weight heatlog e~ Io~refed. ( )Wear ce~cel oeaa~ fo~ zuOp~ for__U~ys. ( ) Suture removal ( ) C~l as soot1 aB pos.-~J~le tot a~nJm~t Test te~u~s given: [~g~ ~P ~EKG ~X-RAY COPY :~BMP ~R~ORDS CDPY CHART ~GLUC. FOU. OW-UP Th~s is our cecommendstion for foIJow-up, ff your Insurm~ce (HMO) requires m physician reterml for c~nsu[tatlc~n, iT iS YOUR RESPONSIBILITY TO OBTAIN THE NE_~. ,~SA R Y APPROVAL ~ wRh: ! ! U~ C~nte, in i ~ L / ~ day~ for: ~auP C!,.R~9ORDS COPY C~A~T OGLUG , HOLY SPIRIT HOSPITAL EMERGENCY CENTER )Ion ~bln, D,O. O~ 006991L Exhibit PATIENT DA Date; )[~- Caller: Telephone Patient: ~'C~ Scheduled/or: on )z~-'7. o;~ at/with ~'~'-~. t-.t,-~r~,.~t Diagnosis: ~ ~,~ Additional Notes: ~ Insurance: Staff Initi"'~ Dr.'s Reply: Date: Staff Initials: 10o48-2002 LONGENBERGER, MICHAEL S: Michael comes today far removal of sutures. Patient was bitten by a neighbor dog. He went to Hoty Spidl Hospital and had sutunes placed. The patient is here for suture removal. O: Shows an 11-year-old boy in no acute distress. The vital signs are normal. The patient has approximately a 6 cm wound on his left pOsterior PROCEDURE: The suture were removed easily and the wound )oaks beautifully healed. A: Suture removal DP: None. TP: I told the father and the patient to wash it on a regular basis. There are no restrictions further care is required David A, Long, M.D./ds T: '10-23-2002 &TIENT iDENTiFICATION NARRATIVE PROGRESS NOTES PAGE ................. FiLE NO. DATE Dr. ,~-..-~ ---- Caller: __ Reason for Calling: Dr's Reply: _~ L.~Z'~ Scheduled Appt,_ . Staff Members Initials: ~ R. ason for Calling: ~ t~ ~ ~' ~ -~ ~ afl MembeCs Initials: ~ ' S~ff Members initials: Dr's Reply: Action Taken by Staff /lamber: Returned Call Called in RX Scheduled Appt Staff Member's Initials: . PATIENT IDENTIFICATION' NARRATIVE PROGRESS NOTES DAT Wark/~eheol Note PINNACLEHEALTH Fam/ly' Medicine Center ~ is able ~ ream to wo~l on ~e ~l}ow]ng resections: ~ None Comm~: Katherine Gallsgher, M.D, Dave Long. M.D, Suzanna Wolanln-Selfl, M,D, PetsJ A~brlght, C,R.N,P. PAGE FILE NO. 04-10-2003 LONGENBERGER, MICHAE'-L S: The patient and his mother'are here because unfortunately the young man still continues to have numbness in his left leg. The patient was bit by a dog back in the fall and he went to Holy Spirit Hospital and had sutures placed. The patient othen~vlse is doing well.. ~His 'ankle sprain when I had seen him before is now completely rescived. O: Shows a 12-year-old boy in ne acute distress. The vital signs are normal Bilateral lower extremities shows that he has normal motor examination, normal pulses for bilateral lower extrem'~t'~es, and also normal DTRs and bilateral patellar and, Achilles reflexes. The patient has a diagonal wound of his mid left posterior caff, It is approximately 5 cm b~' about 1..5 cm in width. The patient had decreased sensation with pinprick in the wound, in fact that is total anesthesia, in an area about 10 cm in diameter aroulqd the wound, he has an area'of diminished sensation. He can feel but it is not as sharp as it is Otherwise the wound is slightly pink, and them is no drainage and no Induration and no tenderness. A: 1. Resolved ankle sprain. 2. Healing wound of the left posterior calf with periwound numbness. · DP: None. TP: I told the mother at this time that i am unaware of any therapy that can bring the sensation back. Secondly she wanted to know if there was anything that could be placed et3 the wound. I did not really that anything being placed on the wound would made any difference. I warned them against using any-.~er.~id ' ~reams to ensure that they would not cause any further atrophy of the skin. Otherwise they are to foll~,.qp with me on aa as-needed basis. , David A. Long, M.D./sgg T, 04-18-2003 Exhibit E GATEWAY Health Plan FEB 0 U S Steel Tower Floor 41 · 600 Grant Street · Pittsburgh, PA 1521%2704 · 412-255-4640 January ~'0, 2004 Stephanie A. Gratkowski Legal Assistant Metzger Wickersham 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 Re: Michael A. Longenberger Dear Ms. Gratkowski: Per your request, enclosed is a printout of claims paid by Gateway Health Plan from October 6, 2002 to the present for the above-referenced member. If you need anything further, please do not hesitate to contact me. Very truly yours, K. A. Barringer General Counsel MB/mc Enclosure Z Gateway Health Plan Member Claim Summary Request Pharmacy claims MICHAEL A LONGENBERGER 22233469'01 Age 12 Gender M Pharmacy Claims from >=10/6/02 Paid Throuc RITE AID # 1074 10/07/0 ~5'-¢ 1074 ~ 10/07/02L 1"'{'~.4~ GIANT PHARMACY #1 I0 10/08/02 39.55 GIANT PHARMACY #110 02/25/03 10.99 GIANT PHARMACY #110 11/04/03 95.78 179.8; h 12/2003 17.72 6,81 3~-.72 6.88 143.89j hsdata\Legal~db 1 .mdb hsdata\Legal\0104_RPT10.xls 1/28/2004 page I of 1 Exhibit F UNITED SERVICES AUTOMOBILE ASSOCIATION 9800 Fredericksburg Road, San Antonio,TX 78288 CLARK DEVERE PO BOX 5300 HARRISBURG PA 17110-0000 January 18, 2004 Policyholder: Michael J. Placzek Reference Number: 2555034-94A-413-6775 Date Of Loss: October 6~ 2002 Loss Location: Camp Hill, Pennsylvania re: Michael Longenberger Dear Mr. DeVere: This is to follow up on my last offer of December 18, 2003 in the amount of $12,000. Please let me know if you have proceeded with filing suit so I can inform my insured. My office hours are Monday thru Friday 7:30 am to 4:00 pm CST. Sincerely, Diana E. Orta Property Examiner Northeast Region Phone: 1-800-531-8222 ext. Fax Phone: 1~800-531-0759 6-1254 2555034 413 - PA - 10/06/02 - 6775 - 63 - C200 15:32 412 263 2288 Ringlet A~soc RINGLER AS'aOCIATE$ (412) 263-2228 (800) 2~9.2225 Fax (412)263.Z188 #7546 ?.003/004 Illustration ! Individually Designed Settlement Michael Longberger D/O/B Z/XO/9 BENEFZT COST GUARANTEED YIELD Guaranteed Lump Sums Tax-Free Benefits $ 10,468 at Age 21 8,500 10,468 · $8,500 $ 10,468 THE ENCLOSED FICURES ARE FOR ILLUSTRATIVE PURPOSES ONLY AND SHOULD NOT BE CONSTRUED AS A CONTRACT. ALL FICURES ARE SUBJECT TO APPROVAL BY THE LIFE INSURANCE CARRIER PPJOR TO THREE GATEWAY CID,ITER, 16 NORTH , PITTSBURGH, PA 15222 Mem~ Natl~l S~d ~le~ T~de EXIBIT I F.%R.05'2004 17:54 412 263 2288 Ringlet Assoo #7732 P.002/002 Life Znsurer Financial Profile Company USAA Life iRa,tings/Rank* :i :,/'. i ...' ' ' ' ':!',': ?, ,":: "ici i'..J A.M. Best Company (Best's Rating, 15 ratings)** A+~- (1) Standard & Poor's (Financial Strength, 20 ratings) AAA (1) Moody's (Financial Strength, 21 ratings) Aa1 (2) Weiss Ratings (Safety Rating, 16 ratings) A- (3) Comdex (Percentile in Rated Companies) 9g * These ratings reflect the opinions of the rating agencies and are not implied warranties of the company's ab111tyto meet Its contractual obligations. All ratings shown ~re current as of Februa~ 1 ~;, 2004. *' Relative financial strength and operating performance In comparison with industry iAssets &, Liabilities Total AdmiRed Assets Total Liabilities Separate Accounts Total Surplus &AVR As % of General Account Assets [Invested Asset Distribution & Yield'" ':' Total Invested Assets Bonds ~) Stocks Mortgages Real Estate (%) Policy Loans (%) Cash & Short-Term Other Invested Assets (%) Net Yield on Mean Invested Assets 2002 (Industry Average 6,42%) S Year Average (Industry Average 7.05%). ]Non-perform!~g, A~set~ aS % of Surpl, Us~& AVA Bonds In or Near Default Problem Mortgages Real Estate Acquired by Foreclosure Total Non-Performing Asse£s As a Percent of Invested Assets Total Value of' Bonds Class 1-2: Highest QualIW Class 3-5; Lower Quality Class 6: In or Near Default Weighted Bond Class Total Income Net Premiums Written Earnings Before Dividends and Taxes Net Operating Earnings 8,774,353 B, 172.499 286300 633.621 7.5% 8)208,443 83,3% 4.2% 0.0% 0.0% 1.6% 0.7% 10.1% 5.93% 6.77~ 0.0% 0.0% 0.0% 0.0% 6,840,160 99.3% 0.7% 0,0% 890,971 lg3,583 85,768 Data for Year-End 2002 from the life insurance companies' statutory annual statement~, All dolier amounts are In thousands. Page 1 of 1 EXIBIT J CONTINGENT FEE AGREEMENT jg/~, rrl~.r/Iqa Z~ca~,_, individually and as parent(s) and natural guardian(s) of pr~c.~e~t b,a~,_q~.,9oer~er' , retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent my son in all claims for compensation and reimbursement for personal injuries, wage loss, and economic and other damages resulting from an accidcnt that occurred on 1. AttorneVs Fees: The fee of the attomeys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. Expenses of Litigation: Actual expenses incurred on the business of the client shall be borne by the client and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses incurred in the prosecution of this claim which have not already been paid by me. We do hereby agree to pay ail expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. ~ We understand that we are responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, we may be asked to advance these costs prior to the incurr'mg of any such expenses or the scheduling of any deposition. Document #: 2341301 3. We hereby fuffi~er agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons. 4. We hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaluing thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. We further authorize our attorney to pay out of any proceeds of settlement or trial any unpaid medical bills for treatments or services made necessary by the injuries sustained in this accident and any workers~ compensation liens. 6. We agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. We hereby further agree that if we decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. We agree that reasonable compensation for Clark DeVere, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, or such higher rate as shall constitute his standard billing rate at the time that the work is performed or the agreed upon pementage fee of one-third of any ultimate recovery, whichever is greater. 8. We agree that our attorney may withdraw from this case at any time after reasonable notice to us, and we agree to keep him advised of our whereabouts at all times and to cooperate at all times li~ the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. Document ii: 182430.1 -2- 9. We also understand that if the investigation reveals that a parent is conlributorily negligent in causing the accident the attomey's representation will solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. 10. I understand and agree that in the event that my account is mined over for collection because of unpaid fees and/or costs/expenses, I will be responsible for payment of the costs of suit as well as reasonable attorney fees incurred in the collection of the monies owed to Metzger, Wickersham, Knauss & Erb, P.C. IN WITNESS WHEREOF, I have signed below on this,(_2 day of /~7/~(t.~4~ ,200~. CLIENT: METZGER, WICKERSHAM, KNAUSS & ERB, P.C. Clark DeVere, Esquire Document #: 182430.1 -3- EX/BIT K RELEASE AND SETTLEMENT AGREEMENT I. RELEASE AND SETTLEMENT A. THE UNDERSIGNED, Michael Longenberger, a minor, by and through Marilyn Zemanik, parent and natural guardian of Michael Longenberger, and Marilyn Zemanik, individually, ("CLAIMANTS") on this day of ,2004, for and in consideration of the sum of $3;500.00, representing upfront cash, paid to us by United States Automobile Association (USAA) ("INSUREW') and the sum of $8,500.00, to fund the periodic payments as provided for in Section 104, Subsection (a)(2) of the Internal Revenue Code of 1986, as amended, specified in Section II, paragraph F of this AGREEMENT, which INSURER contracts and agrees to pay or cause to be paid to the persons or entities named in Section II, paragraph G, the receipt and legal sufficiency of all of which are expressly acknowledged, does hereby forever RELEASE, ACQUIT and DISCHARGE Michael Placzek and Lynn Placzek ("RESPONDENTS"), INSURER and their servants, agents, officers, attorneys, claim adjusters, successors, heirs, assigns, from any and all claims, actions, causes of action, damages, liens of every kind and character, and/or other obligations of every kind and character, including all expenses incurred or to be incurred, on account or arising out of or in any way related to any and all injuries or damages to me, as a result of all occurrences involving CLAIMANTS and RESPONDENTS on or about the 6t~ day of October, 2002, at or near Camp Hill, Commonwealth of Pennsylvania. Al. CLAIMANTS specifically preserve and do not release, acquit or discharge any claim and/or action they may have against any medical provider for any treatment or lack of treatment, including malpractice. A2. CLAIMANTS also specifically preserve and do not release, acquit or discharge any claim, actions and/or right they have to first party benefits through their own insurance policies; social security disability benefits; or any other source for recovery of income loss, work loss, medical benefits, health insurance, disability benefits from any entity, but specifically excluding RESPONDENTS and INSURER. B. THIS RELEASE IS INTENDED TO AND DOES COVER ALL CLAIMS FOR INJURIES AND/OR DAMAGES, WHETHER OR NOT KNOWN TO THE PARTIES AT THE TIME THIS SETTLEMENT AGREEMENT IS EXECUTED, WHICH HAVE RESULTED, MAY HEREAFTER RESULT FROM, MAY HAVE BEEN, OR MAY BE CLAIMED TO HAVE BEEN CAUSED BY OR RESULTED FROM THE DESCRIBED OCCURRENCES. C. As additional consideration for the described payments, CLAIMANTS, for themselves, their heirs, executors or administrators, and assigns, agrees to and does indemnify and hold Docurncnl #300701 harmless RESPONDENTS, INSURER and all others released by this AGREEMENT from any and all legally valid claims, demands and causes of action which have been made, or which may in the future be made by any person, firm or corporation claiming a hospital, medical or other lien which are or could be asserted as a result of the occurrence on October 6, 2002. II. PERIODIC PAYMENTS A. Notwithstanding any other provisions of this AGREEMENT, INSURER is and will remain contractually responsible for all periodic payments under this AGREEMENT. B. RESPONDENTS and INSURER agree that CLAIMANTS (to whom, or upon whose behalf, the periodic payments contracted for in the AGREEMENT are to be made) made claim against RESPONDENTS for damages arising from or involving physical injuries or physical sickness. Those claims, among others, are being released and settled by this AGREEMENT. C. The Parties further agree that all periodic payments specified in Section II, paragraph F, of this AGREEMENT are being funded by the purchase of a "Qualified Funding Asset," as defined in Section 130(d) of the Internal Revenue Code of 1986, from USAA Life Insurance Company, which will provide for payment of the periodic payments, INSURER will be the sole owner of the "Qualified Funding Asset." INSURER guarantees that the periodic payments will be made as specified in the PERIODIC PAYMENT SCHEDULE, D. CLAIMANTS agree: (1) that INSURER is not required to set aside specific assets to secure the periodic payments; (2) that the periodic payments cannot be accelerated, deferred, increased or decreased by CLAIMANTS; and (3) that the periodic payment(s) shall not be, and cannot be, subjected in any manner to sale, transfer, assignment, pledge, mortgage, encumbrance, lien, collateral, or any similar transaction. Any attempted sale, transfer, assignment, pledge, mortgage, encumbrance, lien, collateral or similar transaction is void. E. CLAIMANTS shall have no legal, equitable, vested, or contingent interest in the "Qualified Funding Asset" and their rights against INSURER, the company from whom the "Qualified Funding Asset" is purchased, or against the "Qualified Funding Asset" will be solely those of a general creditor. F. PERIODIC PAYMENT SCHEDULE: $10,468/00 guaranteed lump sum payment, payable February 10, 2012. Document #300701 I G. THE PERIODIC PAYMENT(S) WILL BE MADE PAYABLE TO: Michael Longenberger. H. Any periodic payments to be made after the death of CLAIMANT, Michael Longenberger, under this SETTLEMENT AGREEMENT will be made to the Estate of Michael Longenberger, as designated at the time of settlement (or in writing fi'om time to time thereafter by the guardian of said CLAIMANT with Court Approval) by said CLAIMANT, upon attaining the age of majority, and delivered to INSURER. If no person or entity is designated by said CLAIMANT, or if the person or entity designated is not living at the time of said CLAIMANT'S death, the payment will be made to the Estate of said CLAIMANT. IIL GENERAL PROVISIONS A. It is expressly understood and agreed that this settlement is a compromise of a disputed claim, that the payments provided for may not be construed as an admission of liability by RESPONDENTS or INSURER, and that RESPONDENTS and INSURER expressly deny any liability to CLAIMANTS. B. CLAIMANTS covenant that no representations or promises other than those expressed in this SETTLEMENT AGREEMENT have been made to them in regard to this settlement, that they have carefully read and fully understand this SETTLEMENT AGREEMENT, and that they understand that upon execution of this SETTLEMENT AGREEMENT, all rights, claims and demands CLAIMANTS may have against RESPONDENTS and INSURER, except the contract to make the upfront cash and periodic payments included in this SETTLEMENT AGREEMENT, are completely extinguished. C. SETTLEMENT AGREEMENT is to be construed and interpreted under the laws of the Commonwealth of Peunsylvania. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty o f insurance fraud. Document #300701. I EXECUTED BY ALL PARTIES as of the date first stated above. CLAIMANT: Michael Longenberger, a minor WITNESS: Marilyn Zemanik, individu~ily, and as parent and natural guardian of Michael Longcnberger, a minor INSURER: United States Automobile Association (USAA) Name Title EXECUTED at , this day of ,2004. Document #300701. l VERIFICATION I, Marilyn ZemanJk, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is tree and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities. Dated: June 2, 2004 '~ Document #300202.1 VERIFICATION I, Marilyn Zemanik, as parent and natural guardian of minor Pla'mtiffMichael Longenberger, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of M/nor Plaintiff's Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set foxth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities. ~',?~~,~a Dated: June 2, 2004 ~ gual~dan t~oSMichael Long'eml~er Document #$00202.1 VERIFICATION The undersigned hereby certifies that he is the attorney for Plaintiff Michael Longenberger, by Marilyn Zemanik, as Michael's parent and natural guardian and that the facts in the foregoing Petition for Approval of Minor Plaintiffs Compromise Settlement are true and correct to the best of his knowledge, information and belief, and that said matters relating to the Petition for Approval of Minor Plaintiffs Compromise Settlement are as known to the undersigned as to the clients minor Plaintiff Michael Longenberger, by Marilyn Zemanik, as his parent and natural guardian, said knowledge being based upon information contained in the attorney's file in this matter, and farther states that false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to tmswom falsification to authorities. Dated: June 3, 2004 Clark De're Document #300202.1 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of Petitioner's Petition for Approval of Minor Plaintiff's Compromise Settlement with reference to the foregoing action by first class mail, postage prepaid, this 3r~ day of June, 2004 on the following: Diana Orta Property Examiner United Services Automobile Association 9800 Fredericksburg Road San Antonio, TX 78288 Clark DeVere, Esquire Document #$00202.1 INRE: MICHAEL LONGENBERGER IN THE COURT OF COMMON PLEAS OF CUMBERLAND cOUNTY, PENNSYLVANIA CIVIL TERM DECREE AND NOW, this ~ .~/_. dayof ~ c.~-/c. ,2004, upon consideration of the Petition for Approval of Minor Plaintiff Compromise Settlement, it is hereby ORDERED and DECREED that the settlement for the gross sum of Twelve Thousand Dollars ($12,000.00) is APPROVED. Counsel fees and expenses are found to be fair and reasonable and also approved as set forth below. The distribution is directed as follows: (1) (2) (3) (4) To be paid to Marilyn Zemanik, parent and natural guardian of Michael Longenberger, the sum of $157.00 for the immediate benefit of Michael Longenberger; To be paid to Gateway, the sum of $142.45 in satisfaction of the medical lien; To be paid to Metzger Wickersham, P.C. for counsel fees and expenses - the sum of $3,200.55; and The balance of $8,500.00 to be placed in a structured settlement account, the money to be transferred by United Services Automobile Association (USAA) to the structured settlement account. The account will provide a guaranteed lump sum payment of $10,468.00 to Michael Longenberger at age 21 on February 10, 2012, or if he should die before the payment is made, to his Estate or such other persons or others as shall be designated in writing by him to the insurer or insurers' assignee. Document #300202.