HomeMy WebLinkAbout10-2019DICE
t:F THE P` ;ONTO
PETERS & WASILEFSKI Mt%Q 22 2
By: Stephen F. Moore, Esquire
Attorney ID #62077
2931 North Front Street
Harrisburg, PA 17110
[7171238-7555
Attorney for Plaintiffs
LAUREL HEALTH SYSTEM : IN THE COURT OF COMMON PLEAS
and OF CUMBERLAND COUNTY, PA
THE PMA INSURANCE GROUP,
Plaintiffs CIVIL ACTION G
V. DOCKET NO. O • cW 7
KIM TOMLINSON, JURY TRIAL DEMANDED
Defendant
NOTICE
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the
claims set forth in the following pages, you must take action within twenty (20) days after this
Complaint and Notice are served, by entering a written appearance personally or by attorney
and filing in writing with the Court your defenses or objections to the claims set forth against
you. You are warned that if you fail to do so the case may proceed without you and a
judgment may be entered against you by the Court without further notice for any money
claimed in the Complaint or for any other claim or relief requested by the Plaintiffs. You may
lose money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF
YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR
TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN
GET LEGAL HELP.
Cumberland County Bar Association
32 S. Bedford Street
Carlisle, Pennsylvania 17013
717-249-3166
800-990-9108
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AVISO
USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse
de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion
dentro de los proximos veinte (20) dias despues de la notification de esta Demanda y Aviso
radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en
la Corte por escrito sus defensas de, y objections a, las demandas presentadas aqui en contra
suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el
caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la
demanda o cualquier otra reclamation o remedio solicitado por el demandante puede ser
dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o
propiedad u otros derechos importantes para usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO
INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO O NO PUEDE
PAGARLE A UNO, LLAME O VAYA A LA SIGUIENTE OFICINA PARA
AVERIGUAR DONDE PUEDE ENCONTRAR ASISTENCIA LEGAL.
Cumberland County Bar Association
32 S. Bedford Street
Carlisle, Pennsylvania 17013
717-249-3166
800-990-9108
PETERS & WASILEFSKI
By: Stephen F. Moore, Esquire
Attorney ID #62077
2931 North Front Street
Harrisburg, PA 17110
[717] 238-7555
Attorney for Plaintiffs
LAUREL HEALTH SYSTEM IN THE COURT OF COMMON PLEAS
and OF CUMBERLAND COUNTY, PA
THE PMA INSURANCE GROUP,
Plaintiffs CIVIL ACTION
V. DOCKET NO.
KIM TOMLINSON,
Defendant
COMPLAINT
NOW COME, the Plaintiffs, Laurel Health System and The PMA Insurance
Group (collectively "Plaintiffs"), by and through their attorneys, Peters & Wasilefski, and file
this Complaint and, in support thereof, aver as follows:
1. Plaintiff Laurel Health System ("Laurel Health") is a corporation with a
principal place of business at 3236 Central Avenue, Wellsboro, Tioga County, Pennsylvania
16901, engaged in the delivery of health care services.
2. Plaintiff The PMA Insurance Group ("PMA") is a corporation with a place of
business at 500 N 12th Street, Lemoyne, Cumberland County, Pennsylvania, authorized to sell
insurance policies and adjust insurance claims in the Commonwealth of Pennsylvania.
3. Plaintiffs, Laurel Health and PMA, provided workers' compensation coverage
and provided workers' compensation claims services to Defendant Tomlinson including the
actual adjustment of the workers' compensation claim and the issuance and processing of
various payments, as referenced below, at all times relevant to this complaint.
4. The workers' compensation payments generated and the adjustment of the
workers' compensation claim in Cumberland County, Pennsylvania and Defendant
Tomlinson's failure to repay the same are at the heart of the transactions and occurrences that
form the basis for the present suit.
5. Defendant Tomlinson is an adult individual residing in the Commonwealth of
Pennsylvania at 2740 Newtown Hill Road, Mansfield, Tioga County, Pennsylvania 16933.
6. On or about January 10, 2007, Defendant Tomlinson was injured during the
course and scope of her employment with employer. See report attached hereto and
incorporated herein as Exhibit A.
7. Workers compensation benefits were paid to or on behalf of Defendant
Tomlinson by the Plaintiffs.
8. The workers compensation benefits referenced in the preceding paragraph
totaled $34,401.35. See itemization of payments made on Defendant Tomlinson's behalf
attached hereto and incorporated herein as Exhibit B. The amount of benefits paid on
Defendant Tomlinson's behalf are subject to change, with a resulting change in Plaintiffs'
entitlement to reimbursement, to the extent additional workers' compensation benefits are paid.
2
9. The workers compensation benefits referenced in the preceding paragraphs were
adjusted and processed by Plaintiff PMA, with a place of business in Cumberland County
Pennsylvania.
10. Defendant Tomlinson initiated a third party civil action against Danny Lee
Albright which was docketed in Tioga County, Pennsylvania at Docket Number 1238 CV
2008. That lawsuit, which arose from a motor vehicle accident, was settled by general release
for the sum of $170,000.00. See release attached hereto and incorporated herein as Exhibit C.
See also, correspondence with attachments acknowledging resolution of third party claim for
the sum of $170,000.00 and acknowledging the existence of the lien attached hereto and
incorporated herein as Exhibit D.
11. Pursuant to Section 319 of the Pennsylvania Worker's Compensation Act, 77 P.S.
Section 671, Plaintiffs are entitled to be repaid from Defendant Tomlinson's third party
recovery for workers' compensation benefits paid after a pro-rata deduction for counsel fees
and expenses.
12. Pursuant to Section 319 of the Pennsylvania Worker's Compensation Act, 77
P.S. Section 671, Plaintiffs are entitled to recover $25,311.50 from Defendant Tomlinson after
a pro-rata deduction of fees and costs.
13. Defendant Tomlinson has received the proceeds of the third party settlement.
14. Defendant Tomlinson has not paid any monies over to Plaintiffs. See
communications attached hereto and incorporated herein as Exhibit E outlining discussions
regarding repayment of the $25,311.50 amount identified above. Exhibit E also contains a
3
Pennsylvania Department of Labor and Industry form LIBC-380 which outlines the
reimbursement calculations starting with the total benefit amount paid of $34,401.35 (see
exhibit B) and using Defendant Tomlinson's information regarding counsel fees and costs (see
exhibit D) to arrive at the $25,311.50 amount.
15. Defendant Tomlinson has not paid the sum of $25,311.50 to Plaintiffs.
COUNT I - SUBROGATION
16. Plaintiffs incorporate their allegations as contained in Paragraphs 1 through 15
above as though the same were fully set forth herein at length.
17. Pursuant to Section 319 of the Pennsylvania Worker's Compensation Act, 77
P.S. Section 671, Plaintiffs are entitled to be repaid from Defendant Tomlinson' third party
recovery for workers' compensation benefits with a pro-rata deduction for counsel fees and
expenses.
18. Pursuant to Section 319 of the Pennsylvania Worker's Compensation Act, 77
P.S. Section 671, Defendant Tomlinson is obligated to pay Plaintiffs the sum of $25,311.50.
19. Pursuant to Section 319 of the Pennsylvania Worker's Compensation Act, 77
P.S. Section 671, Plaintiffs are entitled to recover $25,311.50 from Defendant Tomlinson.
WHEREFORE, Plaintiffs demand judgment against Defendant Tomlinson in the
amount of $25,311.50 exclusive of interest and costs, making this case appropriate for
compulsory arbitration.
4
COUNT II - CONVE RSION
20. Plaintiffs incorporate their allegations as contained in Paragraphs 1 through 19
above as though the same were fully set forth herein at length.
21. Defendant Tomlinson initiated a third party civil action against Danny Lee
Aright. That suit was settled by general release for the sum of $170,000.00.
22. A portion of the funds referenced in the preceding paragraph - $25,311.50 was
and is the property of Plaintiffs.
23. Defendant Tomlinson has been asked to provide the sum of $25,311.50 to
Plaintiffs but has not provided the funds.
24. Defendant Tomlinson has converted the $25,311.50 to her own use and control.
WHEREFORE, Plaintiffs demand judgment against Defendant Tomlinson in the
amount of $25,311.50 exclusive of interest and costs, making this case appropriate for
compulsory arbitration.
COUNT III - UNJUST ENRICHMENT
25. Plaintiffs incorporate their allegations as contained in Paragraphs 1 through 24
above as though the same were fully set forth herein at length.
26. Defendant Tomlinson initiated a third party civil action against Danny Lee
Aright. That suit was settled by general release for the sum of $170,000.00.
27. A portion of the funds referenced in the preceding paragraph - $25,311.50 was
and is the property of Plaintiffs.
5
28. Defendant Tomlinson has been asked to provide the $25,311.50 to Plaintiffs but
has not provided the funds.
29. Defendant Tomlinson has maintained the $25,311.50 for her own use even though
she is statutorily and contractually obligated to return the funds to Plaintiff, and therefore, has
been unjustly enriched.
WHEREFORE, Plaintiffs demand judgment against Defendant Tomlinson in the
amount of $25,311.50 exclusive of interest and costs, making this case appropriate for
compulsory arbitration.
COUNT IV - BREACH OF CONTRACT
30. Plaintiffs incorporate their allegations as contained in Paragraphs 1 through 29
above as though the same were fully set forth herein at length.
31. Defendant Tomlinson initiated a third party civil action against Danny Lee
Aright. That suit was settled by general release for the sum of $170,000.00.
32. A portion of the funds referenced in the preceding paragraph - $25,311.50 was
and is the property of Plaintiffs.
33. By operation of law, Plaintiffs have an absolute right of subrogation in the
amount of $25,311.50.
34. By operation of law, Defendant Tomlinson had an obligation to return the
$25,311.50 amount to Plaintiffs but has not done so.
35. By operation of law, a contract existed between the parties hereto, with respect to
the $25,311.50 referenced herein, which required that said funds be returned to Plaintiffs.
6
36. Defendant Tomlinson has breached her contractual obligations by failing to provide
the $25,311.50 amount to Plaintiffs.
WHEREFORE, Plaintiffs demand judgment against Defendant Tomlinson in the
amount of $25,311.50 exclusive of interest and costs, making this case appropriate for
compulsory arbitration.
PETERS & WASILEFSKI
By:
Stephen . Moore, Esquire
Attorney ID #62077
2931 North Front Street
Harrisburg, PA 17110-1250
Date: Z Z - Z-0 N9 [717] 238-7555
Attorney for Plaintiffs
7
8004726254 PMA 10:05:48 o.m 01-26-2010 1 ".1
I hereby affirm that the following fads are correct:
The PMA Insurance Group is a real party in interest. The attached
Complaint is based upon information which I have furnished to my counsel and information
which has been gathered by my counsel in preparation for this lawsuit. The language of the
Complaint is that of counsel and not of me. I have read the Complaint and to the extent that the
Complaint is based upon information which I have given to my counsel, it is true and correct to
the best of my knowledge, information and belief. To the extent that the content of the
Complaint is that of counsel, I have relied upon counsel in making this verification. I hereby
acknowledge that the facts set forth in the aforesaid Complaint are made subject to the penalties
of 18 Pa. C.S. §4904 relating to unworn falsification to authorities.
mine
Authorized Representative of
The PMA Insurance Group
Dated:
Exhibit A
COM MONW94LTH Of P99 WLVARA
OO AIITIaW Of LAM AND 94PJS Y
au11Ow Of wONOW COMINEIGA11010
1171E CAIAiROIt SI MT. 1100 1103
WteEEEINe. M 171ob2E01
ROLL HM1 90040.2303
DATE OF -AT "
01302007
IAONTN DAY Yam
DAPLOYEE
UMOY01
MOWN SOCIAL /aCUFM NWAM
140448330
DATE Of NII
01/10/2007
A
11036TH DAY YPA
M a11C CLAIIS V 1136011111,
First Name KIM Name LAUREL HEALTH SYSTEM
Last Name TOMLINSON Address 32.36 CENTRAL AVE
Address 2740 NEWTOWN HILL. RD Address
Address Cky/Town WELLSWRO State PA mp 16901
CftylTown MANSFIELD Mug PA Zip 16933 comW TIOGA
Counter TKM Telephone PEW 251844910
5708623981
Telephtorlt
Niles OR THIRD PARTY ADRUNI MTOR (if UK kin uredl
INJURY OFORMATION PMAIC
Body Psn(sl affected NICK Ns1ne
Address PO BOX 25250
Type of btjury SPRAIN Address
Description of b*ry THE CAR W FRONT OF KIM HAD STOPPED Cftyfrown LEHIGH VALLEY Stab PA Zip 16002 5250
SO IW APPLIED HER BRAKES TO STOP HER
(0810476-201 8traau CAN 031
VEHICLE WHEN A MACK Tfi= NEAR-ENDED HER :
W880702860
7b*n FM 231642962
Check if Occupatio al Wssase
NOTICE TO EMPLOYER: This Notice shwAd be claw 4 complaad. broferably tyoedl and named Mtn dlrew at du address in to upper left comer.
A copy moat be saw to the ir*red amfilayee with 136 first pow. ltult of eonlpaaadon.
NOTICE TO EMPLOYEES N any 1,1 does setae regarding these paymarlta. comet ds representative named at the bottom of dlia Notice. If you
cannot resolve a p?obfsm with des a ipla l m reprssanadve, you may cam the Btreau at 800482-2383.
Compensation Is payable as follows:
Chock only 9 connpan radon for medical treaatma lmeadhod oft nD less of wepo) will be paid at61M to the workers' componandon Act.
Compensation for madkal trenment is payable from date of injury.
For compensation for medical treatment only. you th0uld not complete riumbers 1 dvough S.
1. Weekly compensation tab $ 423.64 Based an an average weeldy wage of 1 635.46
MOWN DAY YUJI (Compensation for lose of wsgas le payable for Heat 7 days only Il dlasbmity extends
2. Pamenta begin on 01112007 14 or more days: compa»ation for medical tram tont lop-Al e kom dw dab of
VAWIN DAY YEAn i*ry.l
3. Dose fist check mailed 01302007 a er awe OWO do 21-I M, dwok dds bw Dow «5,1 We buk « tli fwo.
4. Payments will hsreaRer be made: V$"* Mal u, X odiw ilI jIL I RTW 01124!2007
Any trmisdon. Suspaeion or modification of dtase payments must be made by -V sane final rewtpR, admi !eve lw or (udteW determination.
or as otherwise provided In the Workers' Compensation Act or Rbguladora of dw Department.
5. It k*ry revolves bas under Section 306(e) (except for disBguanem of the head, face or neckf and annpbyee ha rationed to work, complete
the foEowitg intormation.
(a) Compensation is payable for
weeks
mom
(b) Enpby" repeted to work without lose of bteome an
10 Heating period payable for weeks
(dl Total (el and (c) payable weeks
(o) Credit taken for disability beeeHts paid S.
495 0903
arm CyR'pS..«t, . CYNTHIA L f+IEDEROSTEK Phone Number
Signature of Claims Repieswitad"
UBC•495 REV 9.03 (OVER)
NOTICE OF COMPENSATION
PAYABLE
days for bas or loss of use of
DAY YEAR
days (Up to 01 abow and subject to 7-day waiting paniodf
do".
6. PAmwks
7 DAY WAITING PERIOD APPLIES
Any individual fMng misNsding a incomplete intormatien knowingly and with intent to doksud Is in violotan of Section t 101 of the Famsylvema
WarksW Campanastion Act and may also be udoct to criminal and ciWI penatties through PonnayMania Act 16S.
Exhibit B
rn
N
Elizabeth
Shreve/PMA/PMAGroup
10/0212008 02:45 PM
Elizabeth J. Shreve, CISR
Claims Representative
Ph. (717) 730-8082
Fax (717) 730-8180
To CSC Baddoad/PMA/PMAGroup@PMAGROUP
cc
bcc
Subject Fw: Kim Tomlinson v. Laurel Health System W880702660
c.i.l email from iW attny re lien frwd to d.cxaine
The information contained in this e-mail message is confidential and may be legally privileged. It is
intended solely for the addressee. Access to this email by anyone else is unauthorized. If you are not the
intended recipient, any disclosure, copying, distribution or any action taken or omitted to be taken in
reliance on it, is prohibited and may be unlawful. When addressed to our clients any opinions or advice
contained in this email are subject to the terms and conditions expressed in the governing PMA client
engagement letter.
-- Forwarded by Elizabeth ShrevelPMA/PMAGroup on 1010212009 02:44 PM -
ElFsabeth
Shrsve/PMA/PMAGroup To Darren Craine/PMA/PMAGroup@PMAGroup
10/0212009 02:34 PM cc elizabeth_shreve@pmagroup.com@PMAGroup
Subject Fw: Kim Tomlinson v. Laurel Health System W880702660
Darren,
See below. These #s are correct, again, only presuming, but I believe his disagreement is with the LOC.
Thanksl
Liz
Elizabeth J. Shreve, CISR
Claims Representative
Ph. (717) 730-8082
Fax (717) 730-8180
The information contained in this e-mail message Is confidential and may be legally privileged. it is
intended solely for the addressee. Access to this email by anyone else is unauthorized. If you are not the
intended recipient, any disclosure, copying, distribution or any action taken or omitted to be taken in
reliance on it, Is prohibited and may be unlawful. When addressed to our clients any opinions or advice
contained in this email are subject to the terms and conditions expressed in the governing PMA client
engagement letter.
---- Forwarded by Elizabeth Shreve/PMA/PMAGroup on 10/0212009 02:33 PM -
-Bruce Vickery -
<truce@gv-ew•corm- To <Elizabeth_Shreve@pmagroup.com>
10/0212009 02:32 PM cc
Subject RE: Kim Tomlinson v. Laurel Health System W880702660
m
w
rtnw_ "I
Liz...I am sorry, however, those lien numbers are not correct...
I would love to get this resolved ...but those numbers are not
right ...for reasons I have stated in the past.
-----Original Message-----
From: Elizabeth Shreve@pmagroup.com
(mailto:Elizabeth Shreve@pmagroup.com)
Sent: Friday, October 02, 2009 2:15 PM
To: Bruce Vickery
Cc: Elizabeth Shreve@pmagroup.com; Darren Craine@pmagroup.com
Subject: Kim Tomlinson v. Laurel Health System W880702660
Bruce,
Darren relayed to me that the below figures represent settlement.
Please be advised that I am not interested in resolving the case.
Therefore, please reimburse us our lien amount as follows:
Paid Medical: $31,435.87
Paid Indemnity $2,965.48
Thank you!
Liz
Elizabeth J. Shreve, CISR
Claims Representative
Ph. (717) 730-8082
Fax (717) 730-8180
The information contained in this e-mail message is confidential and may
be legally privileged. It is intended solely for the addressee. Access
to this email by anyone else is unauthorized. If you are not the
intended recipient, any disclosure, copying, distribution or any action
taken or omitted to be taken in reliance on it, is prohibited and may be
unlawful.
When addressed to our clients any opinions or advice contained in this
email are subject to the terms and conditions expressed in the governing
PMA client engagement letter.
"Bruce Vickery"
To
<bruce@gv-law.com
<Elizabeth_Shreve@pmagroup.com>
cc
10/02/2009 10:47
rn
AM
Subject
Elizabeth...
I continue to have 25K in my escrow...
21k for you and 4k for my client-and we can get this resolved...
A Tioga County fact finder will resolve the consortium claim in our
favor ...I continue to be prepared to prove this.
Bruce L. Vickery Esq.
Exhibit C
VS Elizabeth
Shreve/PMAMMAGroup
02111/200910:59 AM
Elizabeth J. Shreve, CISR
Claims Representative
Ph. (717) 730-8082
Fax (717) 730-8180
v
To CSC Backload/PMAIPMAGroup@PMAGROt1P
cc
We
Subject W880702660 6.1 3rd party settlement release form
The information contained in this e-mail message is confidential and may be legally privileged . It is
intended solely for the addressee. Access to this email by anyone else is unauthorized. If you are not the
intended recipient, any disclosure, copying, distribution or any action taken or omitted to be taken in
reliance on it, is prohibited and may be unlawful. When addressed to our clients any opinions or advice
contained in this email are subject to the temps and conditions expressed in the governing PMA client
engagement letter.
- Forwarded by Elizabeth Shreve/PMA/PMAGroup on 021111200910:59 AM -
NoRaply ppmagmup .corn
02111/2009 09:56 AM To "Shreve, Elizabeth " <Eliizabeth_Shreve@pmagroup.com>
Please respond to cc
NoRep"pmagroup.com
Subject Scan from Xerox WorkCentre
Please open the attached document. It was sent to you using a Xerox
WorkCentre.
Sent by: Guest [NoReply@pmagroup.com]
Number of Images: 2
Attachment File Type: PDF
WorkCentre Location: Harrisburg
Device Name: Harrisburg.4
'W
ScwW.PDF
J PN-OU-2C09 02:22 PM G INN, & V 1 CKERY, F. C, 570 724 Me P.02
Jai. 9. 2009 7:550 Nofthl;,ld Ins Co - 651-310-4093 Yo. 76 4 P. 2/3
UJV%C} ! 'a_U4
C. n,.
TN$04084.01 867 RELFARE 3e-cL_ pccti.+"?
FOR THE SOLE CONSIDERATION OF
31711-Aft, the receipt and sufficiency whereof is hereby acknowledged, the
undersigned hereby recesses and forever discharges kM
kift ad
6/..(, =, their heirs, executors, administrators, agents and assigns,
and all other persons, firms or corporations liable or who might be claimed to
be liable, none of whom admit any liability to the undersigned but all
expressly deny any liability, from any and all claims, dammWe, demeg",
actions, causes of action or suits of any kind or nature *Msoever, and
particularly on account of all injuries, known and unknown, both to person and
property. which have resulted or may in the future develop from an accident
which occurred on or about the 1M day of Jamary, ZMst or near SMfl!fld
Undersigned hereby declares that the terms of this settlement have been
completely read and are fully understood and voluntarily accepted for the
purpose of making a full and final compromise adjustment and settlement of any
and all claims, disputed or otherwise, co account of the injuries end damages
above mentioned, and for the express purpose of precluding forever any further
or additional claims arising out of the aforesaid accident, (Settlnont includes
all liens including the workers compensation lien)
Undersigned hereby accepts draft or drafts as final payment of the
consideration set forth above.
in witness Whereof, " (I1 Ws) have hereunto set DV? (Myl Our) hand
this ST day of _ JMsvixy 20a
Kim Tomlinson
Ter nso.-
Attorney Bruce ry
In presenos ofwtnsss: le-
SAN- -2C^?
C2 22 ?M JINN. 9? VICKERY. P. C. 570 724 7686 F. 0?
m
OWN & ak
d. "TXAY CLARK
k! OtIt011AtYl??
ram dco? Moen*
116 mak 9teeet
Wdlaboeo PA 16901
(570) 724-9281
Fans (6") 726.2916
CERTIFICATE OF DISCONTINUANCE
COMMONWEALTH OF PENNSYLVANIA
COtJNTY OF TIOGA
I, MARY KAY CLARK, Prothonotary of the Court of Common Pleas in and for
said Co wry and State, do hereby certify that the can of TERRY TOMLINSON and KIM
TOMLINSON, husband and wife vs. DANNY LEE ALBRIGHT, is hereby mwked SETTLED,
SATISFIED, AND DISCONTINUED as the same appears of record in said Court at No. 1238-
CV-2008.
WITNESS my hand and seal of dw said
c Wel cons lvania, this
?l
eday o 20.
MARY Y CLIftL Prothonotary
Exhibit D
Raymond E. Ginn, jt.
(570)724.6600
Kim and Terry Tomlinson
2740 Newtown Hill Road
Mansfield, PA 16933
GINN & VICKERY, P.C.
Attomeys at Law
P.U. Box 34
Wel6boro, PA 16901
Pax (570) 724-7686
In Re: Tomlinson vs. Albright
January 21, 2W9
v v v oA%..V%4 t4/
5, bcL? c"a ?
Z
( ?d-t-s?
rvL+, 1494
Bruce L. Vickery
(370) 724-6600
c2 ?
Poatrlt' Fax Nuts 7671 °ia
V e (?
TO ?oRi
co?n.pa. co. ..
DISBURSEMENTS CREDIT
Received check from Northland Insurance S 170,000.00
In settlement of lawsuit
Check payable to Ginn & Vickery, P.C. $ 44,919.00
Fees-$44,200.00 (26%) plus costs of $719.00
(see attached)
Check payable to Terry Tomlinson $ 18,762.15
$25,000 (15% of settlement for loss of
Consortium less pro rata share of
legal fees and costs paid to Ginn & Vickery
Check payable to Kim Tomlinson $ 81,318.85
$144,500 less pro rate share of legal
Fees and costs paid to Ginn & Vickery
Balance being held in escrow for
Settlement with PMA for lien $ 25.000.00
170,{1S14.4? 11 MAU
Breakdown of each check:
Kim Tomlinson: Terry Tomlinson:
$1449500.00 S25,500.00
Share of Fees - 37,370.00 Share of Fees - 6,630.00
Share of Costs - 611.15 Share of Coats - 107.8_5
PMA Lien (hold) - 25
$ 81,318.85 $181,762.15
10'd 989L 6ZL 01.5 '0 'd 'AN X01 A I 'NN f 0 WV 83 : 01 6003-1 l -033
Ginn &. Vickery, PC
PO Box 34
23 Easi Avenue
Wellsboro, PA 16901
Ph: 570-724-6600 fax:570-724-7686
Terry Tomlinson
2740 Newtown Hill Road
Mansficld, PA 16933
File #
Attention: Inv #
RE: TOMLINSON, KIM and TERRY TOMLNSON vs. Danny Lee Albright
DISBURSEMENTS
Jan-15-07 Copying 4 00
Jan-16-07 Copying 1.00
Postage 0.78
Jan-17-07 Postage 0.78
Postage 0.63
Jan-26-07 Police Report 8.00
Postage 0 39
Jan-27-07 Medical rccords from SSM14 for Kim 30 79
Tomlinson
Feb-02-07 Postage 0.39
Feb-07.07 Postage 1.11
Mar-08-07 Postage 0.87
Jun-07-07 Copying 46 L 0.25 11.50
Jun-08-07 Postage 2 (a 0.41 0.82
Jul-20-07 Postage 0.41
Jul-23-07 Copying 54 C 0.25 13.50
Postage 2.33
Jut-30-07 Copying 0.50
Postage 0.41
Aug-07-07 Medical Records-Kim Tomlinson from Laurel 10.00
Health in Mansfield
Aug-08-07 Copying 4 @ 0.25 1.00
Postage 0.41
Oct-09.07 Postage 0.41
January 21, 2009
491-001
6077
ZO 'd 9891 PZL OL5 '0 'd 'A83XO l A I 'NN I J WV 6e:01 6002-11-83j
jnvoi,+c V-. 6077 rup, ? - -
act-10-07 Copying 0.50
Postage 0.41
CXt-30-07 Copying 8 c@ 0.25 2.00
N cw-09-07 Medical records of Kim Tomlinson from Dr. 28.96
Raboub
Nov-29-07 Copying 1.00
Postage 2 @ 0.41 0.82
Dec-06-07 Copying 0.25
Postage 0.41
Dec-10-07 Copying 13 a 0.25 3.25
Postage 1,14
Mar-07-08 Postage 2 @ 0.41 0.82
Mar-17-08 Copying 0.25
Postage 0.41
Apr-11-08 Medical records from Geisinger Medical Ctr 64.31
for Kim Tomlinson
Apr-17-08 Copying 46 @ 0.25 11.50
Postage 1.99
Aug-05-08 Copying 0.50
Postage 0.42
Aug-14-08 Medical Records-Kim, Tomlinson-Mansfield 26.25
Laurel Health Center
Copying 13 @ 0.25 3.25
Copying 0.50
Postage 0.76
Postage 0.42
Aug-25-08 Records from Elite Therapy for Kim 7.34
Tomlinson
Aug-26-08 Copying 6 @ 0.25 1.50
Postage 0.59
Sep-17-08 Copying 0.50
Postage 0.42
Postage 0.42
Sep-22-08 Copying 0.50
Postage 3 @ 0.42 1.26
Sep-26-08 Copying 0.25
Postage 0.42
Oct-01-08 Medical Records-Kim Tomlinson-(Mansfield 14.08
Center)
Oct-02-08 Copying 7 @ 0.25 1.75
Postage 0.76
00
co 'd 9991 HL 0L5 'O 'd 'AS3AO I A '8 'NN I O WV 62:01 60OZ- I 1-833
Invoicr. #; .5 77 Page 3 1anuary zi. zvvy
Oct-"A-08 Medical Records from Geisinger Medical Ctr 58.09
for Kim Tomlinson
Oct-;)9-08 updated Records from Elite Therapy for Kim 7.59
Tomlinson
Oct-10-08 Copying 36 (a7 0.25 9.00
Postage 1.85
Oct-31-08 Copying 10 a, 0.25 2.50
Postage 2 `, 1.17 2.34
Nov-20-08 Facsimile 0.30
Nov••24-08 Photocopies 110
Copying 0.50
Facsimile 1.00
Postage 3 (a) 0.42 1.26
No--25-08 Copying 0.50
Postage 0.42
Dec..04-08 Medical Records-Kim Tomlinson-(Mansfield 8.96
Center)
Copying 1.00
Facsimile 1.25
Dee -30-08 Nile Writ of summons 100.50
Service of Writ of Summons 100 00
Jan-05-09 Serve Writ of Summons-Fayette County 150.00
Jan-09-09 Facsimile 0.50
Postage 0.42
Jan-13-09 Facsimile 0.25
Totals $720.17
Total Fees, Disbumements $720.17
Total Fees, Disbursements $720'17
Previous Balance 50.00
Previous Payments SO.00
Balance Due Now S720.17
Balance Of Unused Retainers $0.00
bO 'd 999L OZL OL5 '0 'd 'A83)(01 n 'B 'NN 10 WV OE : O I 60OZ-11-831
.cam
GINN S VICKERY P.C.r KIM TOMLINSON AND
TE8A7 TOMLINSON
P.uu. BOX
WSLLSBOR0, PA 16901
W, -31 1-1
1 A C
es 1/..IrIM.. u1..1
nl.r w. "M
gain row, = eta-fin
(M) W-b"
IN PAMKOT OFt
AMUNTs
PAYSM:
I NSUM s
POLICY NOr
OCCUR NOt
UNIT NOi
DATE OF LOSS:
Northland Insurmce Company
M116Ng AA/rea
No. 455202
FULL AND FINAL PAYPWT FOR ALL OLA116 YUK J101I LY
INJURY INCLUDING ALL BPWIALB/1I=6
$170.000.00
GINN $ YICKNPIY P.C.. XIN TOMLINSON AND IO _ SBU7GD NO DATZ: II 01%19/00
ALBRIGHT. DANNY FEWMAL ID: •?N*??*??
TN604084 TRAM COVZi 713
000001
002
01110/07 EXANINNN CO=t W
Id ¦..6M1t.. hw.c : .
? M.N w. teN
, pellfl-an
DETACH AND RETAIN THIS STATEMENT
Northland Insursou Company
Wfa1 Fup Ba+R, N.A.
4" fto ohm
Nd rlq, M ow
CNiCN MTN
01/12/00
I
PAY ¦ One Hundred Seventy Thousand and NO/100 Dollars
I To
THI
OINN A VICKERY P.C., KIM TOMLINSON AND
OF TERRY TOMLINSON
P.O. BOX 34
WEL3.SBORO, PA 16901
0000045820211 1:09L9004651:
Main low
11-+1
no
cam rium
455202
11010 IF NOT CASNED WITHIN In DAYS
VOID OVER $170 000.00
20-92592
50 'd 989L bZL OL5 '0 'd 'A33?f0IA $ 'NNI O WV 0£ ; Oi 60OZ-1 I-633
COMMONWEALTH OF PENNSYLVANIA THIRD PARTY Social Security Number: 14544$330
DEPARTMENT OF LABOR 8t INDUSTRY ca
BUREAU OF WORKERS' COMPENSATION SETTLEMENT Date of Injury: 01102007
1171 S. CAMERON STREET, ROOM 103 AGREEMENT MM DD YYYY
HARRISBURG, PA 17104.2501
(TOLL FREEI 800.482-2383 PA RWC Claim Number:
If KNOWN!
Emolovee
First Nwne Last Nam•
KIM TOVUNSON
i
Flint Nwe Last Nwo
2740 NEWTOWN HILL RD
Street I
Street 2
0"frown St•n Zip Coe
MANSFIELD PA 16933
County Tako mw
570-662-3981
Employee's Attorney
Num•
Bruce Vickery
Firm Notes
Strw 1
SUM 2
ny own State Zip Coe
T640Me10 PA Attornry 10 Number
Employer
Nom
LAUREL HEALTH SYSTEM
swat 1
ATTN: GENE YAJKO
32-36 CENTRAL AVENUE
ew,t tt• p CW*
Wellsboro PA 16901
Fewtty
TIOGA
T•laplwr FEIN
251644910
Insurer or Third Party Administrator (if self-insured)
Wmp
PMAIC
s><ept 1
PO BOX 25250
Street 2
City1rown State Tip Coe
LEHIGH VALLEY PA 8001 2520
TslapWprle Bureau Coe
888 4762669
Ct•
"
LE IGH
Claim Numbr FEIN
W880702860
Insurer's Attorney
380 0306
UBC-380 NEV 3-0e (Pq p 11
Name
Firm Nerns
Street I
,rest
Citylrown ntp zip Coe
Tsleph PA At-?Num
(OVER)
CALCULATION INSTRUCTIONS FOR COMPLETING BACK OF FORM
#1 - Enter the total amount of money received by the employee from the third parry litigation.
#2- Enter the total amount of indemnity and medical benefits paid by the employer to the employee at the
time of the third parry recovery.
N3.- Enter attorney fees and other expenses paid by the employee to obtain recovery in the third party action.
t4 to p8 --Perform the calculations in the right column and enter the results into the center column.
In accordance with section 319 of the Pennsylvania Worker's Compensation Act, the parties herein have agreed to the following
distribution of proceeds received from _ Third party defendentls) , third party:
BASIC RECOVERY INFORMATION - Complete this section for all third party settlements. Calculation
I . Total Amount of Third Party Recovery
2. Accrued Workers' Compensation Lien
a. Indemnity Benefits 2,985.48
b. Medical Benefits 31.435.87
3. Expenses of Recovery
4. Balance of Recovery
1.
170,000.00
2. 34,401.35
3. 44,919.00
14, 135,598.65
= 01 (minus) N2 1
PRESENT DISTRIBUTION OF PROCEEDS - Complete this section to calculate the amount of proceeds the employer is eligible to
receive as of 1121/09 (date through which Accrued Workers' Compensation Lien (02) calculated).
5. Accrued Lien Expense Reimbursement Rate 5. 20.24% =M2 (divided by) 01 x 100
----------------
8. Expenses Attributable to Accrued Lien S• 9, 089.85 =X3 (times) x5
7. Net Lien (Amount employer to receive) 7. 25, 311.50 = #2 (minus) N8
FUTURE DISTRIBUTION OF PROCEEDS - Complete this section to calculate how much the employer must reimburse the employee
for expenses used to acquire the third party recovery on future compensation liability. Note: This section Is to be completed only If
the total mnount of the Third Party Recovery (#1) is greater than the amount of Me Accrued Workers' Compensation lien (a21.
8. Reimbursement Rate on future compensation 8. 28.42 % .................. = 83 (divided by) 01 x 1
liability.
9. The Employer/Insurer is responsible for 28. % (M8) of any future weekly benefits and medical expenses to satisfy it
obligation to reimburse its pro rata share of Employee's fees and expenses until the subrogation interest is exhausted:
135,598.85 (#4). Thereafter, the Employer/Insurer is responsible for 100% of any compensation liability.
Further Matters Agreed Upon:
Counsel for plaintiff avers and agrees that fee and costs are true and correct
and not mcfaced futtber.
Employedcarrier disputas loss of consortium by plaintiff as no court or jury fording
supports the claim meals by plaiatitf.
Employee's Signature
Employee's Attorney Signature
Insurer's Signature
Insurer's Attorney Signature
DATE OF THIS AGREEMENT: 10/02/2009
MM DD YYYY
Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania
Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.
Auxiliary aids and services are available upon request to individuals with
disabilities..
Equal Opportunity Employer/Program
LISC-380 REV 346 (Page 21
-----Original Message-----
From: El-izabet-'-!_Shreve@pmagroup.com
Lmailto:Elizabeth_Shreve@pmagroup.com)
Sent: Thursday, November 12, 2009 12:01 PM
To. Bruce Vickery
Cc: El-zabezh_Shreve@pmagroup.com; Darren-Craine@pmagro,,-,p.com
Subject: Fw: W380702660 Kim Tomlinson v. Laurel Health
Bruce,
I'm emailing to further clarify that any reso_ution oT the scarring ( n re 2rence to
t:2
below offer) will be subject to the provisions of the workers' Compensation Act which
_udes future credit offset.
T l-: a n k you ''.
Elizabeth J. S.^.reve, CiSR
CIaL:nns Representative
Ph. (717! 730-8082
Fax (717; 730-8180
The =.. Or atlc^: contained in this e-mail message is confidential and may be legally
Dr'Vlleye„'.. t __ -in;_erded solely for the addressee. Access to this emai_ by anyone ease
1s na,_i-_?':or_?ed. i you are not the intended reC_oi nt, any ' i-i-sc_os'1r copying,
d_ _._ t_ ._ _ any ken CmitL_ to Ge Lekeit r2 _an c on 1-, is pro ?._u ted
and may be unlawful.
When addressed to our clients any opinions or advice contained in this email are subject
to zhe ter^ls and condfziorts expressed in the governing PMA client engagement letter.
----- _orwarced by Elizabeth Shreve,/PMA/PNLAGroup on 11/12/2009 11: 42 AM
Elizabeth
n-e e/PMIl./PNA'-rc,
T3
"P?r u:re ViCiCerV'r
<?oruc??ag-?-1a'?r.ccm>
1/12/2009 10:24
cc
A:my@y^'•7-ia*4. ccm, Darren.
Craine/PNT2/PMAGrouo@PMAGrouc,
s`m@pwlegai.com,
o-_'-s.,- _.re?pmagrcup.com(aPMAGr
Jt.cle'_'_
r•a'._o1
ouo
W880702660 Kim Tomlinson
Health (Document ink: __izabeth
Shreve'
Bruce,
The offer to resolve the entire claim has been off the table for some time now. I had
eT_ewed this a w:ile ago with our claims manager and we do not wish to resolve the claim
via a Compromise and Release. I am willing to resolve the scarring at the 15 weeks and we
can do this via Stipulation if you are agreeable to this. As for our lien, obviously the
pay out of scarring increases our lien amt, and the lien issue is now being handled by
Darre Craine who referred it 1.o counsel, Stephen Moore at Peters & Wasilefski to recoup
?.-^: y resol';tion of the outstanding lie:? wi11 have incLude dir. Craine and
Attny 'Moore, both of which I have copied on this email. Mr. Moore can also assist us with
..,e st1p1_atlcn paperwcrK _f you are agreeable to the 1D
'sl;<S rnr the scarring.
Tha- ks
Liz
Elizabeth J. Shreve, C7SR
Claims Recresentative
Ph. (717) 730-8082
Fax (717) 730-8150
The infor~:at1c.. contained in tnis e-mail message is confidential and may be legally
privilege-. is intended solely for the addressee. Access tC t is email by anyone else
is unal_._ :.zed. If you are not the intended recipient, any disclosure, copy 1ng,
dis___bbut_J--n v_ any action taken or omitted to be taken in rella-^ce on it, is prohibited
and may un'awful.
When addressed to our clients any opinions or advice CCntalned in t:1s email are subject
to ..ne terms and Condltlons expressed in the governing PNl; client engagement letter.
"3_uce `•Iic'keryn
Subject:
.?ruCe?q+J- 13?r? . COm
<EliZar2tC': StlreVc3pcmaQr^vup...,Cm>
10/05/2009 03:47
°N! <p .y` ^v- law. com>
Pr'or correspondence
Liz...we had ofeviousiv discussed these figures ...(these are based upon 3? LOC vs. the 12%
that Terry Tomlinson settled for) ...and the weeks for the scarring claim is very/
Gns2- , IB=...nonEt%eless my _lient would 11ke to get this resolved... _V a' Thanks, Bruce
Bruce,
Based on a Comp Rate of $423.64 at 15 weeks for specific loss = $6,354.60 this is the
amount w'hic;1 will increase the indemnity portion of our lien.
rIe would .`lave have C&R documents drags uo that incorporate 111_is .
If you accept a zero C&R to include the specific loss, futu__ medical and indemnity
benefits in exchange for us reducing our _Len by $7,500 in cQrsiderati.cn _3 future
med=cal bene___s, their t%e amount that would be reimburse: to the carrier would be
$20,698.35.
This is how I arrived at the above figures:
1. Total Amount of Third Party Recovery $164,900 (this is incorporating the 3% reduction
for Loss of Consortium„ 2. Total WC Lien includes the unpaid specific loss! $40,534.8, 3.
Expense of R.ecc-very 50,189 ($719 plus $49,470 which is 30% of the
$164,900)
4. Balance Of Recovery $124,365.19
?. Accrued Lien Expense Reimbu.rsemenz Rate 21t."58% 6. Expense %t`_trib'-1tacie to Accrued __en
$12,336.46 7. Net Lien !Amount Employer to
eceive) $28,193.35
Deas_ ___ me know .? _.._S is ace` atle ar-d if ss.. the.. we c'an roce=J 3
?nri`% .1`7_.
_lnSel ^_ Sd _ne caperwork -ort!-.e _.v1 will incl_? the form.
i'nan:{s '.
z
Eza qtr: ?.._eve, Ci3R
Claims Reo eSentati ve
(-17; 730-3082 17, 30-S i8'3
T:-.e lnt0=ma`_1cn contained n ti.i.S e-ma_l message is COi:f1'? n`__? and may oe 1c'a31 1,1
iv ileged. S inLe:-_ded solely for tl:e_ addressee. Access to ,.-;is e-mail by 1-,yone else
is un3"utnorized. if loll are not the intended recLpient, any .._sclosure, copy ng,
dIstr1b _tio - o_ any aLt _?n taken o= omit i=ed to be L ,, i in __ Lance _ LS 0r3;'Eed
...:id may ce '_ la',iful.
51. ad. ess=.. _.? 0. _ n_S 3:11 Opl^_ORS oC ,3d-7L e C=___: `d _n. `..IS c .a?
o terms a',.'.i cond.'=Oi,S e_Xpres_ed in t Pe governi^'j PIMA c1Le?t ,_me- e` c
'Bruce Vickery,
<br'uce@gv-law.com
cc
cuc ec
02/10/2009 02:54
PM
<Elizabeth_Shreve@pmagroup.com>
RE: Tomlinson
Hi L-i z...based upon this proposal... would you please let me know how I have to write
a deck to You for...?...Thanks... Bruce
-----Orig_na1 Message -----
crom: Eli7miDe-b.-Shreve@pmagrou-).com
?Imai1 .Elizabeth Shreve@pmacrcup.com]
Sent: zriday, January 30, 2009 12:30 PM
To: Bruce Vickery
Cc: lizabeth Shreve@pmagroup.com; Darren-Craine@pmagroup.com
Subject: Re. Tomlinson
yr ce,
",,illL need a cocy cf the settlement documentation related to the trd par--,/ claim to
dim-,ume, = ml file a:-,d befcre we can finalize anY settlement.
My - ^er o - i^at 7 ?j, aVe aVai a1-', t0 yo- is
'Pie rIi ! re-,J!,io°_ .^i1-1 _ __en ty C7 5,00 _.. cons 1dera__ or.
a-:d Release cf Mledicai and indemnity benefits. A n
pay- en.- z
related tc scarring would fuftner increase cu Lien.
.re scarring 15 weeks of compensation. However,
lien and what vie excect to recover.
f a 'globa'l Comp_cmLSp
y add tonal
As we previously discussed reso'vina
as stated this further increases cur
_-ease oe wised that si_Ce the 3rd party settlemenr_ has been reso' vej, 'Ne are co_ng to
be 4nn talon-- c=redit on future lien.
ii =n?s LS unacceptable to yot:.r c''ient, please send u_ ti_,., s2ttlem.esettlement OCllme.LdtiOR,
reimbblrsemer.t check for , l_ c..rren_ Lien to date and we P-repare t:-e IEC380.
Please _dvise wit'nin 7 busineSs days as to your det?rmi.,a_io A!-:
. - revoked
P`;1 on 21/1,10/009.
Thank yc,?,
L 2 z
Elizabeth J. Shreve, CTSR
Claims Representative
Ph. ( 717) 730-8082
Fax (717) 730-8180
"he _n. ormation contained n this e-mail message is confidential and may be legally
^vri"Ti?eged. I_ is intended solely for the addressee. Access to this email by anyone else
is unauthorized. if you are not the intended reciaient, any disclosure, copying,
diStrlbution or any action taken or omitted to be taken in reliance Orl it, is prohibited
and may be unlawful.
W' e^ addressed to our clients any opinions or advice contained in this emali are subject
`o t ----ms and conditions excressed in the governing PIMA client" er.gagemei..t. 2t7er.
"Bruce Vickery"
To
cc
Subject
<bruceagv-law.com
<El_zabeth Shr_-re@Nmagrou?.?,m.>
01/30/2009 11:27
Ail
Tomlinson
!Fmbeldec image moved to file. ;Embedded image moved to
f?1e:
cC3- 3.gi )
_CJ1C16,i39.?1f
1Z. please let me '.Know if we could compromise with the payment o= $ x,0-10 n future
medical Paymert...thanks ...
Bruce L. vickerv Esq.
PETERS & WASILEFSKI
By: Stephen F. Moore, Esquire
Attorney ID #62077
2931 North Front Street
Harrisburg, PA 17110
[7171238-7555
Attorney for Plaintiffs
LAUREL HEALTH SYSTEM
and
THE PMA INSURANCE GROUP,
Plaintiffs
v.
KIM TOMLINSON,
Defendant
t='.
;~ T
- ~~„~,
,,~ ~
2D(o J~~ L i ~ ` ~; r
~ a~a Q ~ ~r:a,
j _ ~-:~.
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PA
CIVIL ACTIrJN
DOCKET NO. 10-2019'
JURY TRIAL DE N~
PRAECIPE TO DISCONTINUE ACTIiON
TO THE PROTHONOTARY OF CUMBERLAND COUNTY:
Kindly mark the above-captioned matter as discontinued.
Respectfully submitti
PETERS & WASIL
By/~
Stephen . Moore, E quire
Attorney ID #62077 I ',
2931 North Front Street'
Harrisburg, PA 17114-150
[717] 238-7555 '
Attorney for Plaintiff
Date: ~ ~' ~ ~ ~ ~
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that I served a true and correct copy of the
foregoing, Praecipe To Discontinue Action, on all counsel of record and parties of
interest by placing the same in the United States mail, first-class postage prepaid, at
Harrisburg, Pennsylvania on this~~day of July, 2010, and addressed as follows:
Bruce L. Vickery, Esquire
Ginn & Vickery
P.O. Box 34
23 East Avenue
Wellsboro, PA 16901
Kim Tomlinson
2740 Newtown Hill Road
Mansfield, PA 16933-8439
PETERS & WASILEFSKI
~~