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HomeMy WebLinkAbout10-3309DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHEVY CHASE, Plaintiff v. DEWEY MATTHEWS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ocket No.: i 10 - 330 r,, o ~:. ~' i • 1:E y -..- ~ ~~ Civil Action -Law ~ <~ : ~' ~'- _ ; COMPLAINT `" ~~ „ NOW COMES, Dialysis Corporation of America d/b/a DCA of Chevy Chase, by and through its attorney, Capozzi & Associates, P.C., and makes the following Complaint for a money judgment against Defendant, and in support thereof, respectfully avers as follows: Plaintiff, Dialysis Corporation of America d/b/a DCA of Chevy Chase ("DCA of Chevy Chase"), is a registered Pennsylvania corporation having its principal place of business at 27 Miller Avenue, Lemoyne, Cumberland County, Pennsylvania 17043. 2. DCA of Chevy Chase is an operating subsidiary of Dialysis Corporation of America ("DCA") 3. Defendant Dewey Matthews ("Patient" or "Defendant") is an adult individual with a last known address at 5913 Crooked Creek Drive, Manassas, Virginia 20112. 4. DCA of Chevy Chase provides dialysis treatments and services to its patients. 5. On or about November 10, 2006, Defendant executed a Consent for Hemodialysis Agreement ("Consent Agreement") to allow Defendant to receive regular dialysis treatments from DCA of Chevy Chase as scheduled by his physician and DCA of Chevy Chase. A true and correct copy of the Consent Agreement is attached hereto and incorporated herein as Exhibit «A „ ~Qa •OD P~ A`i'I`y e~.~a~~ao ~,# a~asol 1 6. On or about November 10, 2006, Defendant executed a Patient Assignment and Authorization of Payment of Insurance Benefits Agreement ("Assignment and Authorization Agreement"), which required the Defendant to assign and forward insurance benefits that he received for the dialysis treatments from DCA of Chevy Chase. A true and correct copy of the Assignment and Authorization Agreement is attached hereto and incorporated herein as Exhibit «B „ 7. Paragraph 1 of the Assignment and Authorization Agreement provides that Defendant "hereby assigns, transfers and sets over to DCA of Chevy Chase monies and/or benefits to which the Patient is (or maybe) entitled from any insurance ...provider ...as well as any others who maybe financially liable for the Patient's dialysis treatments and services and related medical care by and/or at DCA of Chevy Chase, including health insurance benefits .. . for which the Patient is entitled, to cover the costs of dialysis treatment and services ...." 8. Paragraph 2 of the Assignment and Authorization Agreement provides that Defendant "hereby authorizes and directs that payment of all insurance benefits...relating to any charges and costs incurred as a result of dialysis treatments and related services and medical care provided to the Patient by and/or at DCA of Chevy Chase, be paid and remitted directly to DCA of Chevy Chase...." 9. Paragraph 3 of the Assignment and Authorization Agreement provides that Defendant "hereby acknowledges that the monies or benefits to be paid by the Patient's insurance provider ...for the charges, costs and fees incurred by DCA of Chevy Chase in its provision of dialysis treatments and related services and medical care to the Patient is and shall at all times remain, the property of DCA of Chevy Chase...." 2 10. Paragraph 3 of the Assignment and Authorization Agreement further provides that Defendant "hereby covenants and agrees that in the event that any payment of insurance benefits .. is sent to the Patient...that the [Defendant] will promptly and unconditionally forward such payment directly to DCA of Chevy Chase." [emphasis added] 11. Paragraph 5 of the Assignment and Authorization Agreement further provides that Defendant "hereby acknowledges that, not withstanding the foregoing assignment and authorization of benefit payments to DCA of Chevy Chase, the Patient shall be responsible for any and all charges and costs billed by DCA of Chevy Chase for dialysis treatments and related services ...and that DCA of Chevy Chase is authorized to bill the Patient directly for payment of such charges and costs." 12. -DCA of Chevy Chase, at the special insistence and request of Defendant during the period November 10, 2006 through August 31, 2007 ("Dates of Service"), provided numerous separate dialysis treatments ("Dialysis") at the rates and on the dates set forth in DCA of Chevy Chase's business records ("Account Statement"). A true and correct copy of the Account Statement is attached hereto and incorporated herein as Exhibit "C." 13. To date, Defendant has failed and refused to pay as required pursuant to the Assignment and Authorization Agreement and the Account Statement in the amount of $38,178.20. 14. On October 28, 2009 and December 3, 2009, DCA of Chevy Chase's counsel mailed to Defendant demand letters, which provided information on how to pay the debt owed to DCA of Chevy Chase. A true and correct copy of the demand letters are attached hereto and incorporated herein as Exhibit "D." COUNT I -BREACH OF CONTRACT 15. Paragraphs 1 through 14 are incorporated herein by reference. 16. The rates and total charges set forth in the Account Statement are just and reasonable and are the rates that Defendant agreed to pay for the Dialysis. 17. Under the terms of Defendant's policy with his insurance provider, Blue Cross/Blue Shield, Defendant received monthly checks from Blue Cross/Blue Shield pursuant to the claims filed by DCA of Chevy Chase. 18. Defendant's insurance provider did not always pay 100% of DCA of Chevy Chase's claims, which resulted in Defendant owing a co-pay to DCA of Chevy Chase ("Co- pay"). 19. Pursuant to the Assignment and Authorization Agreement attached as Exhibit B, Defendant was required to transfer the payments he received from Blue Cross/Blue Shield directly to DCA of Chevy Chase on a monthly basis. 20. The amounts that Defendant received from Blue Cross/Blue Shield pursuant to the claims submitted by DCA of Chevy Chase are indicated in the third column of the Account Statement, which is marked "Blue Cross/Blue Shield Paid." 21. As provided from Blue Cross/Blue Shield's records, Defendant received a total of $38,178.20 from Blue Cross/Blue Shield for the Dialysis treatments during the Dates of Service. 22. During the Dates of Service, Defendant did not transfer any insurance payments from Blue Cross/Blue Shield to DCA of Chevy Chase for the Dialysis treatments, as referenced in Exhibit C. 4 23. The total amount of principal that has become due and owing by Defendant to DCA of Chevy Chase as a result of his failure to transfer the insurance payments that he received and his failure to pay his Co-pay is $38,178.20 24. To date, Defendant has failed and refused to pay the total amount due as provided under the Account Statement and the Assignment and Authorization Agreement. 25. DCA of Chevy Chase has been financially damaged in the amount of $38,178.20, plus interest and costs of collection. 26. Defendant's failure to pay his Co-pay, his failure to transfer the insurance payments, and his failure to cure his default with DCA of Chevy Chase pursuant to the Assignment and Authorization Agreement constitute a breach of contract. WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Chevy Chase, demands judgment against Defendant in the sum of $38,178.20, plus interest at the legal rate of 6% per annum from the date of the judgment. COUNT II -QUANTUM MERUIT -UNJUST ENRICHMENT If this Honorable Court should find that an express contract did not exist between DCA of Chevy Chase and Defendant, which is denied, then, in that event, DCA of Chevy Chase pleads the following alternative cause of action in quantum meruit against the Defendant. 27. Plaintiff incorporates paragraphs 1 through 26 of this Complaint as if set forth at length herein. 28. Having requested DCA of Chevy Chase to provide the dialysis treatments and DCA of Chevy Chase having done so to the benefit of Defendant, Defendant became liable to DCA of Chevy Chase for the just and reasonable charges for the Dialysis. 29. The Defendant has been unjustly enriched by accepting the Dialysis. 30. The rates reflected in the Account Statement as Exhibit C are the just and reasonable rates for dialysis treatments and services. 31. The total value by which Defendant has become enriched on account of the Dialysis is $38,178.20, as is more specifically reflected in the Account Statement. 32. DCA of Chevy Chase has demanded Defendant pay this amount, but Defendant has failed to do so. 33. To date, the Defendant has not paid the total amount due. WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Chevy Chase, demands judgment against Defendant in the sum of $38,178.20, plus interest at the legal rate of 6% per annum from the date of judgment. COUNT III -CONVERSION OF MONEY 34. DCA of Chevy Chase incorporates Paragraphs 1 through 33 of this Complaint as if set forth herein. 35. Defendant was aware that due to the contractual relationship between Defendant and DCA of Chevy Chase pursuant to the Assignment and Authorization Agreement, the insurance payments Defendant received from Blue Cross/Blue Shield properly belonged to DCA of Chevy Chase. 36. Defendant had a legal and contractual duty to safeguard and forward the insurance payments by Blue Cross/Blue Shield made payable to Defendant to reimburse DCA of Chevy Chase for the Dialysis it provided to him. 37. During the Dates of Service, Defendant's insurance provider paid to him $38,178.20. 6 38. During the Dates of Service, Defendant did not transfer any insurance payments made by Blue Cross/Blue Shield payable to Defendant to reimburse DCA of Chevy Chase. 39. Defendant intentionally and permanently retained possession of the monies owed to DCA of Chevy Chase by failing to transfer a total of $38,178.20 of the insurance benefits Blue Cross/Blue Shield paid to him as required under the Assignment and Authorization Agreement. 40. Defendant's intentional possession of and his failure to forward the Blue Cross/Blue Shield insurance monies to DCA of Chevy Chase for the Dialysis provided to Defendant constitutes conversion. 41. DCA of Chevy Chase has been financially damaged by Defendant's conversion in the amount of at least $38,178.20. WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Chevy Chase, demands judgment against Defendant for conversion in the sum of $38,178.20, plus interest at the legal rate of 6% per annum from the date of judgment. Respectfully submitted, Capozzi & Associates, P.C. Dated: S lti rv By: /~~ Michael M. Jerominski, Es ire Attorney I.D. No. 92977 2933 N. Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff 7 r ~ o>~s~s cc~xroi~TYarr ol~ An~.I~xaA DCA 8h, CHE"VY C'~ASi~ Ct'11~SENT F4~~QDYALYSYS Patient: ~T ~~~~ ~ Nannbm-: ~ D ~ 1 ~~~ Date: ~ I. the ullttecsignsd patient; to tha undetsi~ted paractt or guardian of tI>a abvva patient who is vadar Y 8 years of ige or othscw~ige irespsble of titlg; horaby requask and euthoci~ Dr. artd whornaver he or s~ may clgsignat~e as his or her assoamGe or assistant to aalrni~nister to >xte (a~ ~ the above ttaQaed }patiestt) the proc~otlure known as hetnode'atysis, under suia_h cor,~diti~n~s~tas s6a11 be detr~niaed •'7 ~ ~IySLG18C) {$~ 111 ~CC. ~ ~g~ t~ ~6(~ ~l.uu ~o]1('i1C$~ r17~~ ~d ~~(A1S tSt3bliShE~ by t~tC abflVe riatr-ed I?ialy3i3 Unit i[i carcyic~ 0>Yti lib heruodl3ilysis program. Yz has beau incplaiae,d to me tlsaa heen~dialysis is a psnordura used is the ,rasa of pates with imgaument of failure of kidney funceozr by which taatait~ carnpotte~~ts of the blood am separated by a sarzti~,tla su~#auce which petmi#s the passage of certain molecules aAd hinders t#txd of others when tl~e blood is aircEtlated through an arti5cial kidney, called a dialyzer, I ut~derstazzd tha# thore are diffedeu# types of e+goprnent aanpIoyed foe the,dialysis t1'~1L1C13t 8n~d di~'earent types of ai'ti$018i kidrieyg Ed~IY~~ lased ri tho pl~OCeSB. 1 aclatawleKlgt that the posst~tlC risks Arid complic~tiaus of hene~sly'sis such as b~1t not ]'united tc> leakage ofthe dialyzes, cl~tt~ges is blood prtssatre and c>aslfuaatioa of equipment - avetacplaitr,.~b_y.~a~frssi ger~om~l c~~?ialysis~'t,~~.apt, on behalf of myself andloz tltt above patient the dialysis try with all paternal risks. snd. coutpli~tic~s. I also uraderstaad that arty disorder, which afflicts tYte, ran Itavc effects am my treatataat and an tztyeelf during the time that Y am roc~vtag a dialysis try btYt that this fact do~x czar attar that the dialysis treatment baci anything ~ do with the developauent of the ptvblem related tcs this c~nrtdition. Y furrtltter coc~mt ~ the sdlttististrati+~ of such dtvgey Eiarssfusiaas of blood or blood compoavauts, or any other tr+eacta~aclt and testing, including HIV &~tu1g, c~artmed necessary nr dasirabla iA the jet of the physician (s) in attaride. T am aware that the practiea of utediciat is not an exact scieatce, acad 1 acknawledgs that tto guarantet, warranty of represdnta~tioa wha#aoaver has beast ofl'ered os made to me or aayoa~e an my baltal£cancerctizag the results of tha lvemodialysis procedure. g'e: or .. / Legal Guer+liaa or Parent i~tNa>nz:'~y ~~:y~_ n~:~1_~a 7 ~ ~ ~-' nen Fo~su+~toas tr,~n.a iaroa EXHIBIT BT/6tfi ~d 35~7f~,? M~ ~0 tom('! 9Z9~L5JI~E bL~69 L89Z ., iC1IALY6fM5 CORI'O1tATIpTT OF AMBRiCA pA~~` ASSY+GNT AND AUTII03tIZATIt~N QT gAY1~iENT' OF ~fiiSDRANC~ ~FNEFI7'S Fatty= bCA ott~cvv Mass r----- Patirttt Names ,~_~~,~ ~ y pa6ont ID~k,~ ~. ASSI+G~VT swr The u~de:tx~ed huxby aaeagna„ traast~rt end sect over to DCA ~ Ctiavy Chaco >aonies aacUar beAefroa to wldch de Paa3cra u (~' ttay 6a) enfi~t f~aaa aay interance aadlair beaieh Dane ~vFder exr iratio~oat, staoa. o0ttttly or boat ~ y~ iocludiag tba hiedicaaz iatti+mnoe progxan~, ae a~ at aasy others who may be ~aamcialir liable fat t~ Path's d3alyaSt anaameats and se:vioea and e+elated roodical Dace ts~ e+adlar a Dfrl of Chevy Chiase, iaotu~ding health iastomaoe Ir~tp. tat~or nnadical~btrsr~c aad atlu+r medical payment aweragc cr ddher palmy cowta~ for w6loh ll3e P"aotieat is t"o~ad. cv ovv~' ttie cmoe Qf dfaiypt ttesia~# and se:veoer and nay other medirol ogre rendered m the ~titat by andlor at DCA+ofQuvy Chase. z. AUTI~l1tY~A'C~4N' i?F P~-YlI-~EIVT OF IN55UIC`E B$1~TTS 1bn nndersi~d bttaby sudwai~ and dlracts tliMt payment of all ia~amoce benetlts, inclw~tg ivtedirote tt~ d ep~licablo. relatatg to aqy a~'~ and aosa lnw:red as a irwu]t of dialyaic t~ceemneact and t~tatott savhrat and me+d~al eeYb pro'+rlded. to ~ lit by aad/cr at DCA of Chevy Cbate~ ho paid. amt --- -:amia~l-s~socs~-to~'A~af-~v~ C~sa.a~.aco-a~ith.vtia ~oadded`o~a~.,poanr.trg_ --- aq t~tt at ro~uesentative of DCA of Clmvy Glutrc. ff ib= aadexsigmaif~a insere~e >~~ ar pru des not paovuk foie papme~x of tfce ads os beae$es is dui aw~a of DCA~ of ~vY Gate, flan wadstaignod htaniry fmtbrr authoriaes and the iatta'trnoe popvider tar, aga~rry ~ far ,payaraat of ~ appli~bla iotu:ar~ce iteneSts Iie irss-a tha l~aY~ iA the Patiedc's ttan~e and co deliver rat+d peYaeast !A DCA of Chevy Cl+aae st ice addaas 8S ~. fiurth ie the lusnvetiams peoovldes arts 6C p+rovicied by as a~Got or Suva of DGP- of Chevy Cure. 3~, DEGIVEI'[Y OF Bl~'Y' PAYl1dh:AI'~`S RLCEI'V7~ FROM PI~OVIC1F.~t ~L+e tande~igjned try acktsoKl~es that ttbo mgaies qr bea~tlb to be paid OY ~ Padieot't iitstunacc p~t>yvider yr lpavtrt xgegcy fpr the ebar tthcb and deb ina~rred. by IIDCA of Qrevy Chase in hr provision o4' tiiatytts trea~aante tmd related ttuvitxt and medical cart to tie Patient it and ii~l at all 'fltaa resnala~, t~ p~opeKY of bCA a< Ctwwy Cluwc. and in tia~t~urs t6er~oot ttu ttaderatgaad 1heroDy coaenaailt and ap+ees that ~ tht t~ lenient aa'!' pttyaateat a[ ittsnrtrna braudrts, lnduding ~Cdirars ba0ditt, >r~ trda#c dirrxt(y to the water, twso- nand tin itteurrt;d 1-y DCr1 ai []KVy Chase ss a t~txah ut 1ts p~rpvirlon of d'+aYyirlK ueata~nts and rGtakd serviocs and amdfical cam io Ilu Fat~t lr t+~t ito the Paticot or tsoc6 Patitn!'i gvardlio, attorne~- tn-tact yr rgrr~atetire, as tl~ c~+e mscy br, laadve~»tly yr otbawlae, that tI~ ~ wIq p~uptiy ued t>aotrndWnnal~ forwsrd tech payns~aat directly to ]DCA of Cliery Ciuaac. EXHIBIT Page 1 oft ~ s $'ClZT 3rJCd ~F-rJ 1J1~? .~0 VJQ 3'ZBZL99T0~ t'L ~59 L86LI98/L6 4. »ELEAI~ ~F INF~AI4L~TIQN Tice ~ - a>rdealieas sad vaacesat ~ tt~cc releaisc by DCA od' Quvy ~, ar any of its a~eat$ ar ~~"ea, of all ~ pets of any i~4an.:mca~ or . ewer medical r~r EiaantW in . ~ ~ with say pet~cn. ootpoaatioa to gove:aodt~t at'~9, loclttdittQ: aoir tltat+d~y izt~eaooe a,~ t~th ~ per, wbo ~ so~ialty tia6ta for the >~9 dia>yais ~ ~ r fated ren-ices a: weU as audicat care, wLi~ch iafoamatiost >s ~' far tlha iatiatt, ve~iaaticn aodlor ooa~tmadon a~f o~ clta~ sad oossc w DCA of Cbtivy Chaea ~ the p~n+isiara m tLe Padeas of and- dfalysls tit~reu~ and relates travioeseswell es tneaical more. 3. R~SPaI-F5I8LLI'I'Y F4B FA'YIVYENTS ~'he >zadeor~aod ltat+dby oc><nowledges thaoL notwidicatddia~ de ~ aaagwns+or sad ar~nrisstiott of beateSt paymtass m DCA o2'ty Cbeae~ ttu Ptttitmt X11 ix a~ew~k t+o~ tray ant an ~eC sad costs ix'iled by DCA of chery + ~ dialyaitc a, and tabttad ~vicoa pnavldod and ont oibawice co~sxed ar pswi. by stub tl~ctp.:ty paper ar ~ any, in~ttding, y,rit,1-ont lia¢itatia~ alt drductiblc. co-tns~aaaca sad capuymaut sttwmacs, shad DCA of Cry C~ese #s asthori~ed to bill. tLa Patient dit+ectly t~pay~nt of tam t~arges and r.~. th BEV()CJ~~T'Y The ignod ~'bY aalmcwlod~ges ti+at 1t~is PATIENT ASSICIi+IA~N'1` AND AtITHt'lRl2A'tltJN OF P.AYMFNY' t3F INSiJItANCIr BEA~FI'TS may not: be t+rw+alodd tmttss reaucation is ac~ozapeniad try t~be wrbtDen coteteat t4 jtit4h te'swcatiun by bCA of 6~evy Clsast. 7. P8$~'OCO Th+a wtQd. ~tebi' agroat ~i a pbatoCapX af~t~"~is 3~~'~ i~SSll~Tidi~T-~D AUT~tORT?.I~TIt)I~C OF PAYT~fdrCr (~ IN'SI~I~Nt~ 8]'t'!'S ettall hd oaasdrse~l a: valid as au t~tieiuat far patpoaas baao~ sad may ba cared is ptare cd tlioe anginal wftb t+espect xo each ~ items 1 tlu~ugh S abor~ 5l ~ 'PVl~aeas: le'rtttt Natae: Her Daubs: ~ ~' ~• ~ _ ~ ~ ~jtitti Ai'C Signntg as a guardian, at~033M1dy-~Ll-~Ct 8I rCp~+C6Crit~ILtVe Of 8~81tt, 7I~t~ by Ot~C~ t1161foX and GatCtpfEtC lire inf`otaastioa be~FY: ~ ClJB'~ZC,A'170N OF G1tJA~DLl1~IA~BN$Y-~i~Y+ACTfREPB>lrSENA'Y'1VE T~ uada~igned bere6p oerti$ea tlrsi ttddit is tba duly appoiatad guardian. atoo>~y~icr-fait a~Vor tt~tes~ive of tine abuva-saend~omcd pati~eat, imd tt~t ~a/t~e lads fdl mutbotYty- to eacae!r~e uric tbt:a as bebialf of:urh dependent patient. 5`i~a+bat+e: Vi-itnesa: Print Name: Dane: page ~ of 2 BZIZI 3~t7d 35t0H~ Nl~q ~0 ~d 9Zezi;~9iefr ~L~68 G68S/~BILB DIALYSIS CORPORATION Of A M E R I C A +,_,____ Dewe Matthews p212tt Blue Cross/Blue T t Shield Paid To id DC Amt Pt Owes B k Total Aceouni B is c 11/10-21/2006 $ 8 64.50 $ 8,269.5 S - $ 8,269.50 $ 8,269.50 07/04-31/2007 $ 18,573.86 $ 18,573.8 $ N - $ 18,573.86 $ 18,573.86 08/01-31/2007 $ 11,334.84 $ 11,334. $ - $ 11334.84 _ $ ~~ 11,334.84 TOTALS: $ 38,178.20 S 38,178.2 $ 38,178.20 38178.20 214 Senate Avenue, Suite 300, Camp Hill, PA 17011 • Phone (717) 730-6164 • Fax (717) 730-9133 www.d is lysiscorporation.com EXHIBIT Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 1 of 1 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 208145330 (866)390-0376 Provider Number: 21ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy NumberREA982357988 Clatm # Description of Service Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 71183-1 11 /10/06-11 /21 /O6 ADMIN SUPPLIES EPOETIN 9900 UT IV HEMODIALYSIS TREATMENT 1st 2nd Rev. NDC Billing Date ICD9 ICD9 HCPC Code Number Quantity Charges 11/10/06 A4657 270 1 11.40 11/13/06 A4657 270 1 11.40 11/15/06 A4657 270 1 11.40 11/17/06 A4657 270 1 11,40 11!21/06 A4657 270 1 11.40 Treatment Item Subtotal: 5 $57.00 11/10/06 285.21 J0886 634 1 742.50 11/13/06 285.21 J0886 634 1 742.50 11/15/06 285.21 J0886 634 1 742.50 11!17/06 285.21 J0886 634 1 742.50 11 /21 /O6 285.21 J0886 634 1 742.50 Treatment Item Subtotal: 5 $3,712.50 11/10/06 585.6 90935 821 1 900.00 11/13/06 585.6 90935 821 1 900.00 11/15/06 585.6 90935 821 1 900.00 11/17/06 585.6 90935 821 1 900.00 11 /21 /06 585.6 90935 821 1 900.00 Treatment Item Subtotal: 5 $4,500.00 Claim Subtotal: 15 $8,289.50 Grand Total: 15 58,269.50 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 1 of 5 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 208145330 (866) 390-0376 Provider Number: 21 ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy NumberKEA982357988 Claim # 1st 2nd Rev. Description of Service Date ICDB ICDB HCPC Code Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 81063-1 07104107-07110/07 ADMIN SUPPLIES 07/07/07 07/10/07 EPOETIN<10000/100 UNITS 100 UT 07/07/07 285.21 IV 07/10/07 285.21 HEMODIALYSIS TREATMENT 07/04/07 585.6 07/07/07 585.6 07/10/07 585.6 NDC Billing Number Quantity Charges A4657 270 1 11.40 A4657 270 1 11.40 Treatment Item Subtotal: 2 $22.80 04081 634 99 742.50 04081 634 99 742.50 Treatment Item Subtotal: 198 $1,485.00 90935 821 1 900.00 90935 821 1 900.00 90935 821 1 900.00 Treatment Item Subtotal: 3 $2,700.00 Claim Subtotal: 203 ;4,207.80 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 2 of 5 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 208145330 (866)390-0376 Provider Number: 21ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy Number:KEA982357988 Claim # 1st 2nd Rev. Description of Service Date ICD9 ICD9 HCPC Code NDC Bllling Number Quantity Charges Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 91063-2 07/13/07-07/19/07 ADMIN FEE HEP B 07/16/07 ADMIN SUPPLIES 07/16/07 CAPD; TRAINING 07113!07 585.6 07/16/07 585.6 07/17/07 585.6 07/18/07 585.6 07/19/07 585.6 EPOETIN>10000/100 UNITS 100 UT 07/16/07 285.21 IV HEP B VACCINE 40 MCG IV 07/16/07 V05.3 NEEDLE AND SYRINGE 07/16!07 G0010 771 1 11.40 Treatment Item Subtotal: 1 $11.40 A4657 270 1 11.40 Treatment Item Subtotal: 1 $11.40 841 1 1,000.00 841 1 1,000.00 841 1 1,000.00 841 1 1,000.00 841 1 1,000.00 Treatment Item Subtotal: 5 $5,000.00 Q4081 635 100 750.00 Treatment Item Subtotal: 100 $750.00 90747 636 1 443.68 Treatment Item Subtotal: 1 $443.68 A4657 270 1 0.50 Treatment Item Subtotal: 1 $0.50 Claim Subtotal: 109 $6,216.98 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 3 of 5 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 208145330 (866)390-0376 Provider Number: 21 ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy NumberKEA982357988 Claim # 1st 2nd Rev. Description of Service Date ICD9 ICD9 HCPC Code Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 91083-3 07120/07-07/31/07 ADMIN SUPPLIES 07/24/07 CAPD; DAILY TREATMENT 07/20/07 585.6 07/21 /07 585.6 07/22!07 585.6 07/23!07 585.6 07!24/07 585.6 07/25/07 585.6 07/26/07 585.6 07/27/07 585.6 07128!07 585.6 07/29/07 585.6 07/30/07 585.6 07/31 /07 585.6 EPOETIN>10000/100 UNITS 100 UT 07/24/07 285.21 1V NDC Billing Number Quantity Charges A4657 270 1 11.40 Treatment Item Subtotal: 1 $11.40 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 90945 841 1 365.64 Treatment Item Subtotal: 12 $4,387.68 Q4081 635 500 3,750.00 Treatment Item Subtotal: 500 $3,750.00 Claim Subtotal: 513 $8,149.08 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 4 of 5 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 208145330 (866)390-0376 Provider Number: 21ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy NumberKEA982357988 Claim # 1st Description of Service Date ICD9 d ICD9 HCPC v. Code C Number Quantity lling Charges Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 93113-1 08/01 /07-08/31 /07 CAPD; DAILY TREATMENT 08!01107 585.6 90945 841 1 365.64 08/02/07 585.6 90945 841 1 365.64 08/03/07 585.6 90945 841 1 365.64 08/04/07 585.6 90945 841 1 365.64 08/05/07 585.6 90945 841 1 365.64 08/06/07 585.6 90945 841 1 365.64 08/07/07 585.6 90945 841 1 365.64 08!08/07 585.6 90945 841 1 365.64 08/09/07 585.6 90945 841 1 365.64 08/10/07 585.6 90945 841 1 365.64 08/11/07 585.6 90945 841 1 365.64 08/12/07 585.6 90945 841 1 365.64 08/13/07 585.6 90945 841 1 365.64 08/14/07 585.6 90945 841 1 365.64 08/15/07 585.6 90945 841 1 365.64 08/16/07 585.6 90945 841 1 365.64 08/17/07 585.6 90945 841 1 365.64 08/18/07 585.6 90945 841 1 365.64 08/19/07 585.6 90945 841 1 365.64 08/20/07 585.6 90945 841 1 365.64 08/21/07 585.6 90945 841 1 365.64 08/22/07 585.6 90945 841 1 365.64 08/23/07 585.6 90945 841 1 365.64 08/24/07 585.6 90945 841 1 365.64 08/25/07 585.6 90945 841 1 365.64 08/26/07 585.6 90945 841 1 365.64 08/27/07 585.6 90945 841 1 365.64 08/28!07 585.6 90945 841 1 365.64 08/29/07 585.6 90945 841 1 365.64 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 5 of 5 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 208145330 (866)390-0376 Provider Number: 21 ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy NumberKEA982357988 Claim # 1st 2nd Rev. NDC Billing Description of Service Date ICDB ICD9 HCPC Code Number Quantity Charges Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 83113-1 08101107-08/31 /07 CAPD; DAILY TREATMENT 08/30/07 585.6 90945 841 1 365.64 08/31/07 585.6 90945 841 1 365.64 Treatment Item Subtotal: 31 $11,334.84 Claim Subtotal: 31 $11,334.84 Grand Total: 856 $29,808.70 QMS Focus Release: 6.7.02 Louis J. Capozzi, Jr., Esquire* Daniel K. Natirboff, Esquire Donald R. Reavey, Esquire Brice G. Baron, Esquire Andrew R. Eisemann, Esquire Michael M. Jerominski, Esquire Timothy Ziegler, Reimb. Analyst Karen L. Fisher, Paralegal Jennifer Kain, Paralegal Keyoung Gill, Paralegal ' (6ccnxd in PA. NJ end MD) '• Uiccnscd in PA and MD) Dewey Matthews 5913 Crooked Creek Drive #D Manassas, VA 20112-8665 Ca .<, Y 5 ~~, ~ ~ ~ < - ~' October 29, 2009 Re: Account with Dialysis Corporation of America Account Balance: $38,178.20 plus costs of collection Our Matter No.: 1087-08 Dear Mr. Matthews: 2933 North Front Street Harrisburg, PA 17] 10 Telephone: (717) 233-4101 Fax: (717) 233-4103 www. capo2ziassociates. co m Craig I. Adler, Esq. Of Counsel Please be advised that our law firm represents Dialysis Corporation of America. Dialysis Corporation of America is proud to provide compassionate and lifesaving services to individuals in need. However, in certain situations it becomes necessary for them to take stronger measures to enforce the agreements made by their patients to receive compensation for services rendered. Your account is now seriously overdue. Dialysis Corporation of America firmly believes that they are entitled to receive the above-referenced balance. They have instructed me to attempt to settle this account in an amicable manner, if possible. Although you have 30 days to contact me to dispute the amount, make payment, or make settlement arrangements, we will have no option but to prosecute a lawsuit against you if this issue is not resolved. NOTICE: UNLESS YOU DISPUTE THE VALIDITY OF THIS DEBT, OR ANY PORTION THEREOF, WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE, THE DEBT WILL BE CONSIDERED TO BE VALID. IF YOU NOTIFY OUR OFFICE IN WRITING WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE THAT THIS DEBT, OR ANY PORTION THEREOF, IS DISPUTED, WE WILL OBTAIN VERIFICATION OF THE DEBT AND WE WILL MAIL A COPY TO YOU. THE NAME OF THE ORIGINAL CREDITOR OF THIS DEBT IS IDENTIFIED ABOVE. THIS LETTER AND ALL OTHER COMMUNICATIONS FROM US ARE ATTEMPTS TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. Please make arrangements to settle this delinquent account or you may call me if you have any other questions. 1 trust that you will give this Notice your immediate attention. /kjg cc: Lisa A. Laudeman, DCA Yours truly, Michael M. Jerominski EXHIBIT Louis J. Capozzi, Jr., Esquire* Daniel K. Natirbof~ Esquire Donald R. Reavev Esquire Bruce G. Baron, Esquire Andrew R Eisemann, Esquire Michael M. Jerominski, Esquire Dawn L. Richazds, Esquire Timothy Ziegler, Reimb. Analyst Karen L. Fisher, Paralegal Jennifer Kain, Paralegal Keyoung Gill, Paralegal ' (licensed in PA, N7 And MD) •• (licenud in PA and MD) December 3, 2009 Dewey Matthews 5913 Crooked Creek Drive #D Manassas, VA 20112-8665 Re: Account with Dialysis Corporation of America Account Balance: $38,178.20 plus costs of collection Our Matter No.: 1087-08 Dear Mr. Matthews: 2933 North Front Street Harrisbwg, PA 171 ] 0 Telephone: (717) 233-4101 Fax: (717) 233-4103 www, capozziassociates. Com Craig I. Adler, Esq. Of Counsel As you are aware, our law firm represents Dialysis Corporation of America regarding the above-referenced delinquent account. You have failed to respond to my letter, dated October 28, 2009, attempting to resolve this matter in an amicable manner. Accordingly, you have left me no choice but to advise our client to proceed with a civil Complaint to obtain a Money Judgment for the full amount owed, plus interest, attorney's fees, and costs of collection. Please call or write to me immediately if you would rather settle this matter and make flexible payment arrangements. Otherwise, this will be my final communication to you before we file the civil Complaint to obtain a money judgment for the full amount owed, plus costs of collection. Yours truly, Michael M. Jerominski ~jg cc: Lisa A. Laudeman, DCA THIS LETTER AND ANY FUTURE LETTERS FROM OUR FIRM ARE AN ATTEMPT TO COLLECT A DEBT, AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHEVY CHASE, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff v. DEWEY MATTHEWS, Defendant Docket No.: Civil Action -Law VERIFICATION I, Lisa Laudeman, Reimbursement Manager, do hereby verify under penalties of perjury and upon personal knowledge that the contents of the foregoing Complaint are true and correct. Date: ~ `'~ ~ ~~2~- Lisa Laudeman Reimbursement Manager Dialysis Corporation of America 214 Senate Avenue, Suite 300 Camp Hill, PA 17011 DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHEVY CHASE, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. DEWEY MATTHEWS, Defendant Docket No.: 10-3309 Civil Action - Law PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Michael M. Jerominski, Esquire, counsel for the Plaintiff in the above action respectfully represents that: 1. The above-captioned action is at issue. 2. The claim of the Plaintiff in the action is $38,178.20, plus interest at the legal rate of 6% per annum on the date of judgment and costs. The counter-claim of the Defendant in the action is $0.0. 3. The following attorneys are entered in the case as counsel or otherwise disqualified to sit as arbitrators: 1t7 f ?i zi -11 Lowell R. Gates, Esquire r n Mark E. Halbruner, Esquire Craig A. Hatch, Esquire Clifton R. Guise, Esquire y Sarah E. McCarroll, Esquire Jaime D. Black, Esquire Michael M. Jerominski, Esquire Louis J. Capozzi, Jr., Esquire Donald R. Reavey, Esquire Daniel K. Natirboff, Esquire Bruce G. Baron, Esquire Dawn L. Richards, Esquire Andrew R. Eisemann, Esquire a14. oo Pin ¢7r/ C-PaaAy e ja77Q5 I WHEREFORE, Petitioner prays your Honorable Court to appoint three arbitrators to whom the case shall be submitted. Respectfully submitted, Capozzi & Associates, P.C. Dated: _ I! I /Io By: Michael M. Jerominski, Esquire Attorney I.D. No. 92977 2933 N. Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff 2 DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHEVY CHASE, Plaintiff v.. DEWEY MATTHEWS, Defendant AND NOW, this foregoing Petition, Esquire, and captioned action. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : Docket No.: 10-3309 Civil Action - Law ORDER day of 2010, upon consideration of the Esquire, Esquire are appointed arbitrators in the above- BY THE COURT: P.J. 3 DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF d/b/a DCA OF CHEVY CHASE, CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. DEWEY MATTHEWS, Docket No.: 10-3309 Defendant : Civil Action - Law CERTIFICATE OF SERVICE I hereby certify that I have this day caused a copy of the foregoing Petition for the Appointment of Arbitrators to be served by regular first class United States mail, postage prepaid addressed as follows: Jaime D. Black, Esquire Gates, Halbrunner, Hatch & Guise, P.C. 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 Date: September 1, 2010 4-`mow 1174. Michael M. Jerominski, Esquire Attorney I.D. # 92977 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHEVY CHASE Plaintiff, V. DEWEY MATTHEWS, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 10-03309 - ej- r a ?a ?v co Defendant. : CIVIL ACTION PRAECIPE TO ENTER AND WITHDRAW APPEARANCE TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Kindly withdraw my appearance as counsel of record for Defendant in the above- captioned matter. iv c.. Respectfully submitted, GATES, HALBRUNER, HATCH & GUISE, P.C. Date: B y• Jaime . B1 46k, Esq., Of Counsel Atto r Defendant 1013 Mumma Rd., Suite 100 Lemoyne, Pa 17043 (717) 731-9600 Kindly enter my appearance as pro-se litigant of record for Defendant in the above- captioned matter. Date: JI- De #k, a ews, Pro Se ?jp 591 rooked Creek Drive Manassas, VA 20112 _ri tw) .,.b, CERTIFICATE OF SERVICE I, Jaime D. Black, Esq., do hereby certify that on the h0 day of September, 2010, I caused a true and correct copy of the Praecipe to EnterAVithdraw Appearance to be served upon the following individual(s) by first class mail by depositing same in the United States, postage prepaid, in Harrisburg, Pennsylvania. Michael M. Jerominski, Esquire 2933 N. Front Street Harrisburg, Pa 17110 By: Respectfully submitted, Gates, Halbruner, Hatch & Guise, P.C. Jaime Plaek,JEsq., Of Counsel IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DIALYSIS CORPORATION OF AMERICA, d/b/a DCA OF CHEVY CHASE, PLAINTIFF vs. DEWEY MATTHEWS, DEFENDANT NO. 10-3309 I. t i .. CIVIL ACTION - LAW PLAINTIFF'S MOTION FOR JUDGMENT ON THE PLEADINGS AND NOW this =' day of September, 2011, comes the Plaintiff, Dialysis Corporation of America, d/b/a DCA of Chevy Chase, by and through its attorneys, the law firm of Capozzi & Associates, P.C., and files the within Motion for Judgment on the Pleadings, of which the following is a statement: 1. Plaintiff, Dialysis Corporation of America, d/b/a DCA of Chevy Chase ("DCA"), is a registered Pennsylvania corporation having its principal place of business at 27 Miller Avenue, Lemoyne, PA 17043. 2. Defendant, Dewey Matthews, is an adult individual with a last known address of 5913 Crooked Creek Drive, Manassas, VA 20112. 3. That on or about May 18, 2010, DCA filed a Complaint against Defendant seeking a money judgment to recover monies due DCA, for charges incurred by Defendant for dialysis treatments rendered to Defendant by DCA. A true and correct copy of said Complaint is attached hereto and incorporated herein as Plaintiff's Exhibit No. 1. 4. That on or about June 23, 2010, Defendant filed an Answer to said Complaint. A true and correct copy of said Answer is attached hereto and incorporated herein as Plaintiff's Exhibit No. 2. 5. In Paragraph 23 of said Answer, Defendant neither admits nor denies Plaintiff's allegation that the total amount of principal that has become due and owing by Defendant to DCA as a result of his failure to transfer the insurance payments that he received and his failure to pay his Co-pay is $38,178.20. 6. In Paragraph 28 of said Answer, Defendant neither admits nor denies Plaintiff's allegation that having requested DCA to provide the dialysis treatments and DCA having done so to the benefit of Defendant, Defendant became liable to DCA for the just and reasonable charges for the Dialysis. 7. In Paragraph 41 of said Answer, Defendant neither admits nor denies Plaintiff's allegation that DCA has been financially damages by Defendant's conversion in the amount of at least $38,178.20. In Defendant's Answer, Defendant appears to explain the circumstances pertaining to the debt due and owing in this matter, but Defendant does not deny that dialysis treatments were rendered to Defendant by DCA, and does not state a legitimate defense/objection/dispute to owing the debt due to Plaintiff as stated in the Complaint, and, in fact, admits to the account balance due and owing. 9. As an Exhibit to the aforementioned Answer, Defendant attached a letter he sent to DCA's counsel and Plaintiff, wherein Defendant admits twice to owing the debt in the amount of $38,178.20. 10. That no payments have been made by Defendant to DCA on the debt due and owing as stated in the Complaint. 11. Pennsylvania Rule of Civil Procedure 1029(b) states, "averments in a pleading to which a responsive pleading is required are admitted when not denied specifically or by necessary implication." 12. Pennsylvania Rule of Civil Procedure 1029(b) further states, "a general denial or a demand for proof, except as provided by subdivisions (c) and (e) of this rule, shall have the effect of an admission." 13. The pleadings are closed and time exists within which to dispose of this motion without delaying trial. 14. The pleadings filed of record show that no genuine issue of material fact exists to be tried. 15. Plaintiff is entitled to judgment on the pleadings as a matter of law. WHEREFORE, Plaintiff, Dialysis Corporation of America, d/b/a DCA of Chevy Chase, respectfully requests that this Honorable Court enter judgment in favor of Plaintiff and against Defendant, Dewey Matthews, in the amount of $38,178.20, plus the costs of this action and such other relief as this Honorable Court deems proper and just. Respectfully submitted, CAPOZZI & ASSOCIATES, P.C. Attorney I.D 2933 N. Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff PLAINTIFF'S EXHIBIT NO. 1 DIALYSIS CORPORATION OF AMERICA : d/b/a DCA OF CHEVY CHASE, ; V. Plaintiff DEWEY MATTHEWS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Docket No.: : Civil Action N o 1 -r -e as ?S in COMPLAINT NOW COMES, Dialysis Corporation of America d/b/a DCA of Chevy Chase, by and through its attorney, Capozzi & Associates, P.C., and makes the following Complaint for a money judgment against Defendant, and in support thereof, respectfully avers as follows: 1. Plaintiff, Dialysis Corporation of America d/b/a DCA of Chevy Chase ("DCA of Chevy Chase'), is a registered Pennsylvania corporation having its principal place of business at 27 Miller Avenue, Lemoyne, Cumberland County, Pennsylvania 17043. 2. DCA of Chevy Chase is an operating subsidiary of Dialysis Corporation of America MCA"). 3. Defendant Dewey Matthews ("Patient" or "Defendant") is an adult individual with a last known address at 5913 Crooked Creek Drive, Manassas, Virginia 20112. 4. DCA of Chevy Chase provides dialysis treatments and services to its patients. 5. On or about November 10, 2006, Defendant executed a Consent for Hemodialysis Agreement ("Consent Agreement") to allow Defendant to receive regular dialysis treatments from DCA of Chevy Chase as scheduled by his physician and DCA of Chevy Chase. A true and correct copy of the Consent Agreement is attached hereto and incorporated herein as Exhibit .4A 4% •00 Pz Allr+/ atV 0117,20 12# a 4a8o l 6. On or about November 10, 2006, Defendant executed a Patient Assignment and Authorization of Payment of Insurance Benefits Agreement ("Assignment and Authorization Agreement"), which required the Defendant to assign and forward insurance benefits that he received for the dialysis treatments from DCA of Chevy Chase. A true and correct copy of the Assignment and Authorization Agreement is attached hereto and incorporated herein as Exhibit «B 7. Paragraph 1 of the Assignment and Authorization Agreement provides that Defendant "hereby assigns, transfers and sets over to DCA of Chevy Chase monies and/or benefits to which the Patient is (or may be) entitled from any insurance ... provider ...as well as any others who may be financially liable for the Patient's dialysis treatments and services and related medical care by and/or at DCA of Chevy Chase, including health insurance benefits ... for which the Patient is entitled, to cover the costs of dialysis treatment and services ...." 8. Paragraph 2 of the Assignment and Authorization Agreement provides that Defendant "hereby authorizes and directs that payment of all insurance benefits ...relating to any charges and costs incurred as a result of dialysis treatments and related services and medical care provided to the Patient by and/or at DCA of Chevy Chase, be paid and remitted directly to DCA of Chevy Chase...." 9. Paragraph 3 of the Assignment and Authorization Agreement provides that Defendant "hereby acknowledges that the monies or benefits to be paid by the Patient's insurance provider ... for the charges, costs and fees incurred by DCA of Chevy Chase in its provision of dialysis treatments and related services and medical care to the Patient is and shall at all times remain, the property of DCA of Chevy Chase...." 2 10. Paragraph 3 of the Assignment and Authorization Agreement further provides that Defendant "hereby covenants and agrees that in the event that any payment of insurance benefits ... is sent to the Patient. ..that the [Defendant] will promptly and unconditionally forward such payment directly to DCA of Chevy Chase." [emphasis added] 11. Paragraph 5 of the Assignment and Authorization Agreement further provides that Defendant "hereby acknowledges that, not withstanding the foregoing assignment and authorization of benefit payments to DCA of Chevy Chase, the Patient shall be responsible for any and all charges and costs billed by DCA of Chevy Chase for dialysis treatments and related services ... and that DCA of Chevy Chase is authorized to bill the Patient directly for payment of such charges and costs." 12. DCA of Chevy Chase, at the special insistence and request of Defendant during the period November 10, 2006 through August 31, 2007 ("Dates of Service"), provided numerous separate dialysis treatments ("Dialysis") at the rates and on the dates set forth in DCA of Chevy Chase's business records ("Account Statement"). A true and correct copy of the Account Statement is attached hereto and incorporated herein as Exhibit "C." 13. To date, Defendant has failed and refused to pay as required pursuant to the Assignment and Authorization Agreement and the Account Statement in the amount of $38,178.20. 14. On October 28, 2009 and December 3, 2009, DCA of Chevy Chase's counsel mailed to Defendant demand letters, which provided information on how to pay the debt owed to DCA of Chevy Chase. A true and correct copy of the demand letters are attached hereto and incorporated herein as Exhibit "D." 3 COUNT I - BREACH OF CONTRACT 15. Paragraphs 1 through 14 are incorporated herein by reference. 16. The rates and total charges set forth in the Account Statement are just and reasonable and are the rates that Defendant agreed to pay for the Dialysis. 17. Under the terms of Defendant's policy with his insurance provider, Blue Cross/Blue Shield, Defendant received monthly checks from Blue Cross/Blue Shield pursuant to the claims filed by DCA of Chevy Chase. 18. Defendant's insurance provider did not always pay 100% of DCA of Chevy Chase's claims, which resulted in Defendant owing a co-pay to DCA of Chevy Chase ("Co- pay"). 19. Pursuant to the Assignment and Authorization Agreement attached as Exhibit B, Defendant was required to transfer the payments he received from Blue Cross/Blue Shield directly to DCA of Chevy Chase on a monthly basis. 20. The amounts that Defendant received from Blue Cross/Blue Shield pursuant to the claims submitted by DCA of Chevy Chase are indicated in the third column of the Account Statement, which is marked "Blue Cross/Blue Shield Paid." 21. As provided from Blue Cross/Blue Shield's records, Defendant received a total of $38,178.20 from Blue Cross/Blue Shield for the Dialysis treatments during the Dates of Service. 22. During the Dates of Service, Defendant did not transfer any insurance payments from Blue Cross/Blue Shield to DCA of Chevy Chase for the Dialysis treatments, as referenced in Exhibit C. 4 w 23. The total amount of principal that has become due and owing by Defendant to DCA of Chevy Chase as a result of his failure to transfer the insurance payments that he received and his failure to pay his Co-pay is $38,178.20 24. To date, Defendant has failed and refused to pay the total amount due as provided under the Account Statement and the Assignment and Authorization Agreement. 25. DCA of Chevy Chase has been financially damaged in the amount of $38,178.20, plus interest and costs of collection. 26. Defendant's failure to pay his Co-pay, his failure to transfer the insurance payments, and his failure to cure his default with DCA of Chevy Chase pursuant to the Assignment and Authorization Agreement constitute a breach of contract. WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Chevy Chase, demands judgment against Defendant in the sum of $38,178.20, plus interest at the legal rate of 6% per annum from the date of the judgment. COUNT II - QUANTUM MERUIT - UNJUST ENRICHMENT If this Honorable Court should find that an express contract did not exist between DCA of Chevy Chase and Defendant, which is denied, then, in that event, DCA of Chevy Chase pleads the following alternative cause of action in quantum meruit against the Defendant. 27. Plaintiff incorporates paragraphs 1 through 26 of this Complaint as if set forth at length herein. 28. Having requested DCA of Chevy Chase to provide the dialysis treatments and DCA of Chevy Chase having done so to the benefit of Defendant, Defendant became liable to DCA of Chevy Chase for the just and reasonable charges for the Dialysis. 29. The Defendant has been unjustly enriched by accepting the Dialysis. 04 30. The rates reflected in the Account Statement as Exhibit C are the just and reasonable rates for dialysis treatments and services. 31. The total value by which Defendant has become enriched on account of the Dialysis is $38,178.20, as is more specifically reflected in the Account Statement. 32. DCA of Chevy Chase has demanded Defendant pay this amount, but Defendant has failed to do so. 33. To date, the Defendant has not paid the total amount due. WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Chevy Chase, demands judgment against Defendant in the sum of $38,178.20, plus interest at the legal rate of 6% per annum from the date of judgment. COUNT III -CONVERSION OF MONEY 34. DCA of Chevy Chase incorporates Paragraphs 1 through 33 of this Complaint as if set forth herein. 35. Defendant was aware that due to the contractual relationship between Defendant and DCA of Chevy Chase pursuant to the Assignment and Authorization Agreement, the insurance payments Defendant received from Blue Cross/Blue Shield properly belonged to DCA of Chevy Chase. 36. Defendant had a legal and contractual duty to safeguard and forward the insurance payments by Blue Cross/Blue Shield made payable to Defendant to reimburse DCA of Chevy Chase for the Dialysis it provided to him. 37. During the Dates of Service, Defendant's insurance provider paid to him $38,178.20. 6 38. During the Dates of Service, Defendant did not transfer any insurance payments made by Blue Cross/Blue Shield payable to Defendant to reimburse DCA of Chevy Chase. 39. Defendant intentionally and permanently retained possession of the monies owed to DCA of Chevy Chase by failing to transfer a total of $38,178.20 of the insurance benefits Blue Cross/Blue Shield paid to him as required under the Assignment and Authorization Agreement. 40. Defendant's intentional possession of and his failure to forward the Blue Cross/Blue Shield insurance monies to DCA of Chevy Chase for the Dialysis provided to Defendant constitutes conversion. 41. DCA of Chevy Chase has been financially damaged by Defendant's conversion in the amount of at least $38,178.20. WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Chevy Chase, demands judgment against Defendant for conversion in the sum of $38,178.20, plus interest at the legal rate of 6% per annum from the date of judgment. Respectfully submitted, Capozzi & Associates, P.C. Dated: _ W14110 By. Michael M. Jerominski, Es ire Attorney I.D. No. 92977 2933 N. Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff I a DIALYSIS CORMATION OF AM=A DCA. OF CIHEVY CHASE C4ma FOR HE11sAD>r LlLas pedent: kaawewc _ aete: 4 c LOW uads?>p? *0 undyed Pww or pardise of d,. above patient wtw jx um&r is yeses of e" of O&OW let inc, ofoon+a *v hereby request and wthoriase Dr. mid whol"Ver he or she asay daaigoate as his or bet aasocisae or asiiow to administe to me (or to to above sawed pedew) the W 'e knom as hanodidyais, under such conditioas as" be 4owmased by cite FhY hw (s) in . I op" abide by dw poUciae, rules„ and Nana atiblidsed the above nazied Dialysis Unit aattying out its bwoodlalysit popum It has beca'"ptabW to me dw Iwmdialysia is aprocean Wed in the case ofpatir Vft ia>?easmeat Othilm of kW*sy fwwdm by which ouWn conVor was of the blood sere sepatsted by a sa wean ble substaaoe which patttsits d w pasp of min sbalat>les ad Wmknr that of others whec the blood is cisMaced 6rough an aKificial ladncy, called a dialyser. I iodemtend that dare are diflera t tl?paa of egs4=ant employed for do dialysis tres?ent and Mama types of'attifloid hdadys (Mysm) used in to proem. I aclasoti ** that tie powN6 ricks and ooanplicadaa ofhe modiAlysis such as but act Knitted to lesimp ofthe dialynr, dmqx is blood press m and at hiadon of eQui zm t bdtalf ofmysal m&,or tie above *ew the dialysis tre mast wide edl potemmial rinks acid compricskictis. I" Ufidwftd chit nay d wdar, which afflicts vM an hewer of bm an my ou mart Won aw6W the Mims that I ant raceiviag a dislyus u+eaomat>t bat the ibis fact does not num that the dialysis Iatd ssa?tisag ON do wM the developran t of dhe pr+obleua warms to dus owdium I fu ft consent to the -d-W - -G*of sash dMgK ofblood or blood composts, or aqv wiser bwmaetat end tesatm& indndrag EIIv testiuX deemed necessa y at desirable in than judgamt of the physician (s) in atasdom. I sera away to the practice of umdiciw is not an cad sNaance, and 1 ACIMoMWO that no Purw , wssrmly of t#P=WAWWn wWboetvw has been offered or made to sae or aoyow on my beW oowaning the resuha of the henw&alysis procedure. Ss?tugaee or reeat ?3iareim or Pereesa print N=w mod`''/ t!6i i Oz. - DOW f D b ?'' L oW, *=#1 w EXHIf3 T Rro"d low 11 8t/Ge --VVd 35" AA10 X VW 9ZU59ZBE bZ'68 L88Z15911-0 ., DMLVW CORPORAU(N OFANDWA PAT NT ASSIGWAaNT AND AUTjIORI A nONr OF PAYMFNT OF 14SUJLA,NCE B?FI1"S Faodltyt lD A?afQW Ch] pukaxom - limit &*gpt _ 1. ANIGD UENr The mod hereby sa4pa6, t odbea ad arcs over w DCA of Choy Ckwo moats! a4kc btadht to to Padin it (at a w bey aarf f?o any totaranoe rwila haft ow Power err Wkwt muds„ conmq' or low povwatoeatd apaaoy. Bea )ANtaas peopx6rd, " ak a ary auras who va y be llmaddijr li ibt !kit PadoWs dla"i aasina it and sarykea ad twbi6d not" MR t7 aa/rar at DCA d Chn y-dam, k6d0e 101603010e bftft agar AID" bawoft ad O&w aooee%d pep?oaeae wvaape cr Ww pelby oovatapt hr sikk the Perusal is ad d4 b cow ttre am ofd AY& a was" ad atvioes and say otter o>ediaad orate eead"d bibs Ped w by aa" at DCA atOwq Cbass. 7. •AUTROKLTATMOF PAymm owvauRANM XUNM S The medeaip w ben* awkwap ad dlrecte that p6yeet6at ofa? iawaaooa betadltu, Adalioaor beftS&N if appiicsbie. TIMi to &W 4ba W ad oast beoad a a swa d dint & Muss"M ad entered aarvim "so" arse praridod to the Palm by mUat a DCA adf Cbeq Cbsee. be p a ad tardy DCAL`be?yr-t?aeeam aoomadaooeadth in apeart W e MlfttM" cfDCA ofChevy Cask. If the * brpaaoee policy ar PMM 4006 aotpso>46 hr pews of dw areaafat at butt it the seams d DCA of Chevy Clue, *0 timdwdpod h=4 brdw ad wbm Good (Wools the 0. SPOW 109000" for Proud ati6c gyalloabls havaaoe bad a irate the P+meac fa dae PaW el wens and m drifw acid pe; - oe w DCA at Chevy Chw at ks a J6w et art 8oetb in I* lawroexlaa6 pecvUW ar so be f w4died by ae now a: vrp ve of DCA atCbevy Chm I DAY OF DE 'i' PAYMS M R>TCRnIM FROM PXOVIDElt Ie aedeelred tm+eby adMOWbftW OW Am Hach or beaefs to be paid by tiao Patton aer rmwom eR' I t1? for do 0ba><prr. too W feat inconvtd by DCA of chm Chew is It proviefoee of and rnbtad wrriaa ad a A&M wee to d a PMW it and AMN d all tims nosain, tke peaparty of DCA d Chary O s4 sod iA twee dwil t dw tiamatdp6asl MerNir w"aaatt rued W ft that fa ft east triter ray ptFmraat afi lotaratiaoe ? bdeikan baadltt, wbiefir retade eflnragy oo tba . ao6es and teen lWarrtd by DCA of teary Men at a rmb of Its rmylolon ef ear tnei meot6 and robsed ttiwloen MA a ftd cart to fbt: !arrant b ooas le the Padeat ar past bdoo 't pmd hW abOtrssy. 104M or l4wo statue, a 00 tM my b4 badwetarw or c0awbe, ** tic aadwd feed wm pnwp* sod doooadhionaft forward aA payawu dim* to WA of Clay Cbase. Pop i of 2 at/TT 3EVC1 3iy-" A&3-0 .o VX EXHIBIT 3Z9ZZ9918C bZ:Ge G88ZIti8/t8 4 1. 4o WUZAUOIVV4j0UUnON Tim tmdmdpd bu* odaim od ooze" * im ?elesaoe by DC:A of a yr amt, or my of ias VON ar mpwenprd 44 aidl or paat at AW bdI0=W*k and * or eifLar ar titaurdoi In aster 1 00 ar wdR 4w P, ooav it -14 a aar on I aRt W. b* dhW mW W dd+WW kme WAAar beds rare pmvidar• wbo is tieoaidty liable Loy dm Paidmes dWpk ttoamuote ad mdod eaa<viaaes at wall as m?iCd ans• wbi?b iadOnato?doaK ir>aio ey IIor Aae tea6 vetiDtetlaa swat ooatla>ydatt adpelraaaRit a[rbs?t tad ooate m DCA. dCbavy Csaee mr the proviriaa m OK R?leatoi each di* ds uu aow amd tobod ea4m*gwadl ao mWkw eve. S. R$WORMSOM Y FM PA`!'MEM Tltie amdeaipid bw* oatlcaoaalaatyrt dart, a blYed byDC.A?• lit drII i?ee a? hr ta?? ad d v?rdrs ad of Oww Oho Ex atiaa dl a?eaiaemo IN stbw tvioet 1, m 'dtd ad oat otlw%to W?d ar pared by ari ddtd ** Mar ar VWWMWW a/lNW, wftw Umbkdm alt dede ft w4mamm a and o"mmaat +oawamaa, ad daer DCA of Chevy Cbm b amtbadaedtobilltbs?adaat dia+OCttr tbrp?ymeatt alaa? cber?saad ooete. & RWOd.AinAlrY The UdWWW i=9 adamoWledpea OW WS PATIENT A&SIC3N>rdi3bl'1' AND AUT AMX OF PAYMW OF INSUAA M OMMM may an be my dad ad m so& nvoaedoo it socompedded by alto w: ooaaeat tO Wah terora M by DCA of C b"y Clew, pwilompm -- Tirs W*Ndpad 'Now wm *a AUMORIZA TM OF PAYUM OF x 8 71'3 varll bs ommidsad as vdld a au wiod for pwpow: brew and my to yawed is plane of dro Oftt l Wa aesnect goo ach d Clam 1 ?V?Antt:i Parlat Nam NwT17r, ,ts Dadte. R3 Z, tf' ?i?i `- ItYm ass dV* an SIMAIM GUMU ?.ts-bct of npra a of amt; glossaWimft by mokin ft box and mm "ft bAuwdaa bsbw: 0 tOEii'IT ncATiioN OF GVARDL NAITOW 4"ACr/RZPRZSErt 7WE The =da:dp od baa+eby UMNa? !bat bbW is dw duty aimed p wdku. aaromey aao" =pigs end rf? paMiena:.ad tbst ba/ihe iaa lbll wtlsodo? m aaa iba+a oa Print Name: Wiftww: Dada: PSO 2 of 2 SL/LI 3D1d 3SVM ABED jp vx 9tez6s9Lgc tiL=68 CeaLirrone DIALYSIS CORPORATION Of A M E R I C A Motd ws8212CC flue fiessimuo Shield Pdd To Amt Pt Own TotalACCOnt 10-2 Ulzow 01-3 TOTALS: $ .30 i 73.16 44 $ 178.20 $ i 73.8 $ 1 $ $8178. 20 $ $ 68.50 S it 73AS 1 378.20 S 69.30 $ 18 AS $ 1 .84 36176.20 214 Senate Avenue, Suite 300, Camp Hill, PA 17011 - Phone (717) 730.6164 . Fax (717) 730-9133 -dialysiscorporation.com EXHIBIT L Itemized UB04 Statement Uae1' JSTINE Date: 2/3/09 Page 1 of 1 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 206145330 (866) 390-0376 Provider Number: 21ME Insurer. BLUE CROSS/CAREFIRST Group Number.002320578 Policy NumberREA982357988 Claim 0 Description of Service Data lot ICD9 2nd ICD9 HCPC Rev. NDC Code Number Quantity Billing Charges Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 71183.1 11/10/00-11/21106 ADMIN SUPPLIES 11/10/06 A4657 270 1 11.40 11113/D6 A4657 270 1 11.40 11115/06 A4657 270 1 11.40 11/17/06 A4657 270 1 11.40 11/21106 A4657 270 1 11,40 Treatment Rem Subtotal: 5 $57.00 EPOETIN 9900 UT IV 11/10/06 285.21 J0886 834 1 742.50 11/13106 285.21 J0886 634 1 742.50 11/15/06 285.21 J0886 634 1 742.50 11/17/08 285.21 J0886 634 1 742.50 11/21/08 285.21 J0886 634 1 742.50 Treatment Item Subtotal: 5 $3,712.50 HEMODIALYSIS TREATMENT 11/10106 585.6 90935 821 1 900.00 11113/08 585.6 90935 821 1 900.00 11/15/06 585.6 90935 821 1 900.00 11117/06 585.6 90935 821 1 900.00 11/21/06 585.6 90935 821 1 900.00 Treatment Item Subtotal: 5 $4,500.00 Claim Subtotal: 15 $6,269.60 Grand Total: 15 $8,269.60 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 1 of 5 Facility: DCA-CHEVY CHASE 313ETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 208145330 (866) 390-0376 Provider Number: 21 ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy NumberKEA982357988 Claim 0 let 2nd Rev. NDC Billing Description of Service Date IC09 ICD9 HCPC Code Number Quantity Charges Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 91063-1 07104107-07110107 ADMIN SUPPLIES 07/07/07 07110/07 EPOETIN<10000/100 UNITS 100 UT 07/07/07 285.21 IV 07/10/07 265.21 HEMODIALYSIS TREATMENT 07/04107 585.8 07/07/07 585.6 07/10107 585.6 A4667 270 1 11.40 A4657 270 1 11.40 Treatment Item Subtotal: 2 $22.80 04081 634 99 742.50 04081 634 99 742.50 Treatment Item Subtotal: 198 $1,485.00 90935 821 1 90000 90935 821 1 900.00 90935 821 1 900.00 Treatment Item Subtotal: 3 $2,700.00 Claim Subtotal: 203 $4,207.80 OMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 2 of 5 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 208145330 (866) 390-0376 Provider Number 21 ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy NumberKEA982357988 Claim M lot 2nd Rev. NOC Billing Description of Service Date IC09 ICD9 HCPC Code Number Quantity Charges Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 9106-2 07113107-07/19/07 ADMIN FEE HEP B 07/16/07 G0010 771 1 11 40 ADMIN SUPPLIES 07116/07 A4657 Treatment Item Subtotal: 270 1 1 $11.40 11.40 CAPD; TRAINING 07/13/07 07/16/07 07/17/07 07/18/07 07119/07 585.6 585.6 585.6 585.6 585.6 Treatment Item Subtotal: 641 841 841 841 841 1 1 1 1 1 1 $11.40 1,000.00 11000.00 1,000.00 11000.00 1,000.00 EPOETIN>10000/100 UNITS 100 UT IV 07/16/07 285.21 04081 Treatment Item Subtotal: 635 5 100 $5,000.00 750.00 HEP B VACCINE 40 MCG IV 07/16/07 V05.3 90747 Treatment Item Subtotal: 636 100 1 $750.00 443.88 NEEDLE AND SYRINGE 07116/07 A4657 Treatment Item Subtotal: 270 1 1 $443.68 0,50 Treatment Item Subtotal: 1 $0.50 Claim Subtotal: 109 $6,216.98 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 3 of 5 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 8005 BETHESDA, MD 208145330 (866) 390-0376 Provider Number: 21 ME Insurer. BLUE CROSS/CAREFIRST Group Number-.002320576 Policy NumberKEA982357988 Claim 0 1st 2nd Rev. NDC Billing Description of Service Date ICD9 ICD9 HCPC Code Number Quantity Charges Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 91063-3 07/20107-07131/07 ADMIN SUPPLIES 07/24/ 07 A4657 270 CAPD; DAILY TREATMENT 07120/07 585.6 07/21/07 585.6 07122/07 585.6 07/23/07 585.6 07124/07 585.6 07125/07 585.6 07126/07 585.6 07127/07 585.6 07128/07 585.6 07/29/07 585.6 07/30/07 585.6 07/31/07 585.6 90945 90945 90945 90945 90945 90945 90945 90945 90945 90945 90945 90945 Treatment Item Subtotal: 841 841 841 841 841 841 841 841 841 641 841 841 EPOETIN>10000/100 UNITS 100 UT 07/24/07 285.21 04081 IV Treatment Item Subtotal: 635 1 11.40 1 $11.40 1 365.64 1 365.64 i 365.64 1 365.64 1 365.64 1 365.64 1 365.54 1 365.64 1 365.64 1 365.64 1 365.64 1 365.64 12 $4,387.68 500 3.750.00 Treatment Item Subtotal: 500 $3,750.00 Claim Subtotal: 613 $8,149.08 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 4 of 5 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE B005 BETHESDA, MD 208145330 (866) 390-0376 Provider Number: 21ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy Number.KEA982357988 Claim 0 1st Description of Service Date ICD9 d lCD9 HCPC v. Code C Number Quantity lling Charges Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 93113-1 08101/07-08/31/07 CAPD; DAILY TREATMENT 08101/07 585.6 90945 841 1 365.64 08102/07 585.6 90945 841 1 365.54 08/03/07 585.6 90945 841 1 365.64 08/04/07 585.6 90945 841 1 365.64 08/05/07 585.6 90945 841 1 365.64 08/06107 585.6 90945 841 1 365.64 08/07/07 585.6 90945 841 1 38564 08108107 585.6 90945 841 1 365.64 08/09/07 585.6 90945 841 1 365.64 08/10107 585.8 90945 841 1 365.64 08/11/07 585.6 90945 641 1 365.64 08/12/07 585.6 9D945 841 1 365.64 08/13/07 585.6 90945 841 1 365.64 08/14/07 585.6 90945 841 1 365.64 08/15/07 585.6 90945 841 1 365.64 08116/07 585.6 90945 841 1 365.64 08/17/07 585.6 90945 841 1 365.64 08/18/07 585.6 90945 841 1 385.64 08/19/07 585.6 90945 841 1 365.64 08/20/07 565.6 90945 841 1 365.64 08/21/07 585.6 90945 841 1 365.64 08122107 585.6 90945 841 1 365.64 08/23/07 585.6 90945 841 1 365.84 08/24107 585.6 90945 841 1 365.64 08/25/07 585.6 90945 841 1 365.64 08/26107 585.6 90945 841 1 365.64 08/27/07 585.6 90945 841 1 365.64 08/28/07 585.8 90945 841 1 365.64 08/29/07 585.6 90945 841 1 365.64 QMS Focus Release; 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 5 of 5 Facility: DCA-CHEVY CHASE 3 BETHESDA METRO CENTER, SUITE 9005 BETHESDA, MD 208145330 (666) 390-0376 Provider Number: 21 ME Insurer: BLUE CROSS/CAREFIRST Group Number:002320576 Policy NumberKEA982357988 Claim 0 let 2nd Rev. NDC Billing Description of Service Date ICD9 ICD9 HCPC Code Number Quantity Charges Patient: MATTHEWS, DEWEY 5913 CROOKED CREEK DRIVE MANASSAS, VA 20112 93113-1 0&101/07-08131107 CAPD; DAILY TREATMENT 06130/07 585.6 90945 641 1 36564 08/31/07 585.6 90945 841 1 365.64 Treatment Item Subtotal: 31 $11,334.84 Clain Subtotal: 31 $11,334.84 Grand Total: 888 $29,90810 QMS Focus Release: 6.7.02 Louis J. Capozzi, Jr., Esquire' Daniel K. Natirboff, Esquire Donald R. Reavey. Fsgsir Bruce G. Baron, Esquire Andrew R. Eisemann, Esquire Michael M. Jerominski, Esquire Timothy Ziegler, Reimb. Analyst Karen L. Fisher, Paralegal Jennifer Kain, Paralegal Keyoung Gill, Paralegal ' (I..d m PA. NJ W MD) •• (Immd in PA W MD) Dewey Matthews 5913 Crooked Creek Drive #D Manassas, VA 20112-8665 29, 2009 Re: Account with Dialysis Corporation of America Account Balance: $38,178.20 plus costs of collection Our Matter No.: 1087-08 Dear Mr. Matthews: 2933 North Front Street Harrisburg, PA 17110 Telephone: (717) 233-4101 Fax: (717) 2334103 www.capozziassociates.com Craig 1. Adler, Esq, Of Counsel Please be advised that our law firm represents Dialysis Corporation of America. Dialysis Corporation of America is proud to provide compassionate and lifesaving services to individuals in need. However, in certain situations it becomes necessary for them to take stronger measures to enforce the agreements made by their patients to receive compensation for services rendered. Your account is now seriously overdue. Dialysis Corporation of America firmly believes that they are entitled to receive the above-referenced balance. They have instructed me to attempt to settle this account in an amicable manner, if possible. Although you have 30 days to contact me to dispute the amount, make payment, or make settlement arrangements, we will have no option but to prosecute a lawsuit against you if this issue is not resolved. NOTICE: UNLESS YOU DISPUTE THE VALIDITY OF THIS DEBT, OR ANY PORTION THEREOF, WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE, THE DEBT WILL BE CONSIDERED TO BE VALID. IF YOU NOTIFY OUR OFFICE IN WRITING WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE THAT THIS DEBT, OR ANY PORTION THEREOF, IS DISPUTED, WE WILL OBTAIN VERIFICATION OF THE DEBT AND WE WILL MAIL A COPY TO YOU. THE NAME OF THE ORIGINAL CREDITOR OF THIS DEBT IS IDENTIFIED ABOVE. THIS LETTER AND ALL OTHER COMMUNICATIONS FROM US ARE ATTEMPTS TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. Please make arrangements to settle this delinquent account or you may call me if you have any other questions. I trust that you will give this Notice your immediate attention. Yours truly, /k.Ig cc: Lisa A. Laudeman, DCA Michael M. Jerominski EXHIBIT ? b Louis J. Capozzi, Jr., Esquire* Daniel K Naftoll; Esquire Donald R. 9m0 . a i . Brice G. Baron, Esquire Andrew R Eiseman, Esquire Michael M. JerominsicL Esquire Dawn L. Richards, Esquire Timothy Ziegler, Reimb. Analyst Karam L. Fisher, Paralegal Jennifer Kain, Paralegal Keyoung Gill, Paralegal •( WWW W ?A. W fed ML1) • (Bopped is PA ad MW Dewey Matthews 5913 Crooked Creek Drive #D Manassas, VA 20112-8665 Re: Account with Dialysis Corporation of America Account Balance: $38,178.20 plus costs of collection Our Matter No.: 1087-08 Dear Mr. Matthews: 2933 North Front Street Harrisburg, PA 17110 Telephone: (717) 233-4101 Fax: (717) 233-4103 www, CVozziassociates.com Craig I. Adler, Esq. Of Counsel As you are aware, our law firm represents Dialysis Corporation of America regarding the above-referenced delinquent account. You have failed to respond to my letter, dated October 28, 2009, attempting to resolve this matter in an amicable manner. Accordingly, you have left me no choice but to advise our client to proceed with a civil Complaint to obtain a Money Judgment for the full amount owed, plus interest, attorney's fees, and costs of collection. Please call or write to me immediately if you would rather settle this matter and make flexible payment arrangements. Otherwise, this will be my final communication to you before we file the civil Complaint to obtain a money judgment for the full amount owed, plus costs of collection. Yours truly, 4U4 •? Michael M. Jerominski /kjg cc: Lisa A. Laudeman, DCA THIS LETTER AND ANY FUTURE LETTERS FROM OUR FIRM ARE AN ATTEMPT TO COLLECT A DEBT, AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. December 3, 2009 DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF d/b/a DCA OF CHEVY CHASE, CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. Docket No.: DEWEY MATTHEWS, Defendant Civil Action - Law VERIFICATION I, Lisa Laudeman, Reimbursement Manager, do hereby verify under penalties of perjury and upon personal knowledge that the contents of the foregoing Complaint are true and correct. Date: AN (yo-a `?? Lisa Laudeman Reimbursement Manager Dialysis Corporation of America 214 Senate Avenue, Suite 300 Camp Hill, PA 17011 PLAINTIFF'S EXHIBIT NO. 2 JA ME D. BLACK, ESQUIRE Gases, Halbruner, Hatch & Guise, P.C. Att orney I.D. No. 200705 10'3 Mumma Road, Suite 100 Lemoyne, Pennsylvania 17043 (717) 731-9600 j.black@gateslawfirm.com DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHEVY CHASE Plaintiff, V. DEWEY MATTHEWS, Defendant. FILEDG -CIE SARY Za10 JUN 23 Pit 3: 13 CUE.-' ^ ``'vav?a PRJNS; yL IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 10-03309 CIVIL ACTION ANSWER TO COMPLAINT AND NOW, comes the Defendant, Dewey Matthews, by and through his attorney Jaime D. Black, Esq., and the law firm of Gates, Halbruner, Hatch & Guise, P.C. and files this Answer and in support thereof states the following: 1. Paragraph 1 is admitted. 2. Paragraph 2 is admitted. 3. Paragraph 3 is admitted. 4. Paragraph 4 is admitted. 5. Paragraph 5 is admitted. 6. Paragraph 6 is admitted. 7. No responsive pleading is necessary as the allegation references a document and the document speaks for itself. .is 8. No responsive pleading is necessary as the allegation references a document and the document speaks for itself. 9. No responsive pleading is necessary as the allegation references a document and the document speaks for itself. 10. No responsive pleading is necessary as the allegation references a document and the document speaks for itself. 11. No responsive pleading is necessary as the allegation references a document and the document speaks for itself. 12. It is neither admitted nor denied that Defendant made special insistence and request for DCA to provide separate treatments and proof is demanded thereof. No responsive pleading is necessary as to the business records as they are a document and the document speaks for itself. 13. Paragraph 13 is neither admitted nor denied and proof is demanded thereof. By way of further response, Defendant did speak to a woman at of Dialysis Corporation of America to secure a payment arrangement to settle any monies owed. The woman from Dialaysis Corporation of America did accept an offer for Defendant to pay fifteen dollars ($15.00) per month. However, payment instructions pertaining to the offer were never sent to Defendant and therefore he was unable to commence payments according to the aforementioned agreement. 14. Paragraph 14 is neither admitted nor denied and proof is demanded thereof. By way of further response, Defendant never received a correspondence from Plaintiff s counsel in or around October, 2009. Defendant did contact Plaintiff s counsel after receiving the December 2009 correspondence and during that conversation, Defendant attempted to negotiate a settlement to the monies owed. In that same conversation, Defendant stated he had made a previous arrangement with Dialysis Corporation of America to make monthly payments of fifteen dollars ($15.00). Plaintiffs counsel said he would have to speak to his client regarding this payment arrangement; however, Defendant did not receive any communication from Plaintiff or Plaintiffs counsel until receiving the filed complaint in May 2010. Defendant placed this chain of events in a letter sent to Plaintiff's counsel, again referring a proposal to settle this matter, which was received by Plaintiff's counsel via certified mail on June 1, 2010. A copy of this correspondence is attached as Exhibit 1. COUNT 1- BREACH OF CONTRACT 15. No responsive pleading is necessary. 16. Paragraph 16 is neither admitted nor denied and proof is demanded thereof. 17. Paragraph 17 is neither admitted nor denied and proof is demanded thereof. 18. Paragraph 18 is neither admitted nor denied and proof is demanded thereof. 19. Paragraph 19 is neither admitted nor denied and proof is demanded thereof. 20. No responsive pleading is necessary as the allegation references language contained in a document and the document speaks for itself. 21. Paragraph 21 is neither admitted nor denied and proof thereof is demanded. 22. Paragraph 22 is neither admitted nor denied and proof thereof is demanded. 23. Paragraph 23 is neither admitted nor denied and proof thereof is demanded. 24. Paragraph 24 is denied. Defendant has made efforts to pay the monies owed to DCA by communicating with both Dialysis Corporation of American and Plaintiff's counsel to negotiation payment arrangements. 25. Paragraph 25 is neither admitted nor denied and proof thereof is demanded. 26. Paragraph 26 is a conclusion of law and no response is necessary. To the extent a response is requires, it is denied generally. COUNT 11- QUANTUM MERUIT - UNJUST ENRICHMENT 27. No response is necessary. 28. Paragraph 28 is neither admitted nor denied and proof thereof is demanded. 29. Paragraph 29 is neither admitted nor denied and proof thereof is demanded. 30. Paragraph 30 is neither admitted nor denied and proof thereof is demanded. 31. Paragraph 31 is neither admitted nor denied and proof thereof is demanded. 32. Paragraph 32 is neither admitted nor denied and proof thereof is demanded. 33. Paragraph 33 is admitted. COUNT III- CONVERSATION OF MONEY 34. No responsive pleading is necessary. 35. Paragraph 35 is neither admitted nor denied and proof thereof is demanded. 36. Paragraph 36 is neither admitted nor denied and proof thereof is demanded. 37. Paragraph 37 is neither admitted nor denied and proof thereof is demanded. 38. Paragraph 38 is neither admitted nor denied and proof thereof is demanded. 39. Paragraph 39 is neither admitted nor denied and proof thereof is demanded. 40. Paragraph 40 is a conclusion of law and no response is necessary. To the extent a response is requires, it is denied generally. 41. Paragraph 41 is neither admitted nor denied and proof thereof is demanded. Respectfully submitted, Gates, Halbruner, Hatch & Guise, P.C. Date: 1? o r J ' e . Black, Esq., Of Counsel ey for Defendant VERIFICATION I verify that the statements made in this Answer to Plaintiffs Complaint are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. Dewey ews Dewey W. Matthews 5913 Crooked Creek Dr. Manassas, VA 20112 May 27, 2010 Michael Jerominski Capozzi & Associates, P.C. 2933 North Front Street Harrisburg), PA 17110 Dear Mr. Jerominski, Please be advised in accordance with council's advice, I am sending this letter by certified mail. It is in reference to the civil lawsuit that you have entered into on behalf of your client Dialysis Corporation of America (DCA) docket #l 10-03309. It is and always has been my admission of the debt in the amount of $38,178.20. When first contacted by DCA 1 agreed to pay $15.00 a month. This was a verbal agreement with DCA but they never followed up with any written papers telling me where, when, or how to make those payments. I never received the letter you sent dated October 20, 2009 but did receive the letter dated December 3, 2009. At that time you and I spoke on the phone where again I admitted to the debt. In the phone conversation 1 also agreed to make a monthly payment of $15.00. You then stated that you need to contact your client to see if an arrangement could be made. As with my previous contact with DCA I did not hear anything back from you until receiving the lawsuit paperwork. I am at this point willing to pay $50.00 month payments. Should this satisfy your client please contact me with the appropriate instruction on how I can make the payment. Sincerely, Dewey W. Matthews Cc: Lisa Laudeman, DCA Reimbursement Manager Dialysis Corporation of America 214 Senate Ave., Suite 300 Camp Hill, PA 17011 CERTIFICATE OF SERVICE I, Jaime D. Black, Esq., do hereby certify that on the 'V!tof June, 2010, I caused a true and correct copy of the Answer to Plaintiff s Complaint to be served upon the following individual(s) by first class mail by depositing same in the United States, postage prepaid, in Harrisburg, Pennsylvania. Michael M. Jerominski, Esquire 2933 N. Front Street Harrisburg, Pa 17110 Respectfully submitted, Gates, Halbruner, Hatch & Guise, P.C. By: Jaime )flac]f Esq., Of Counsel VERIFICATION The undersigned hereby states that he is the attorney for the Plaintiff, and that he is authorized to make this verification on behalf of said Plaintiff in the within action, and verifies that the statements made in the foregoing Motion are true and correct to the best of his knowledge, information, and belief, based upon information provided by the Plaintiff. The undersigned understands that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. CAPOZZI & ASSOCIATES, P.C. MiIip V Warholic, Esquire Attorn ID # 86341 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff Dated: ? (d ? ? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DIALYSIS CORPORATION OF AMERICA, NO. 10-3309 d/b/a DCA OF CHEVY CHASE, PLAINTIFF VS. : CIVIL ACTION -LAW DEWEY MATTHEWS, DEFENDANT CERTIFICATE OF SERVICE I, Philip C. Warholic, Esquire, do hereby certify that on this day of September, 2011, I sent, via First Class Mail, a true and correct copy of Plaintiff's Motion for Judgment on the Pleadings to Defendant, addressed as follows: Dewey Matthews 5913 Crooked Creek Drive Manassas, VA 20012 Capozzi & Associates, P. By: / l_, L WI U Philip C. W holic, Esquire Attorney I.D # 86341 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff DIALYSIS CORPORATION OF : IN THE COURT OF COMMON PLEAS OF AMERICA d/b/a DCA OF CUMBERLAND COUNTY, PENNSYLVANIA CHEVY CHASE, Plaintiff V. CIVIL ACTION - LAW DEWEY MATTHEWS, Defendant NO. 10-3309 CIVIL TERM = IN RE: PLAINTIFF'S MOTION FOR ,r-- -' ;-, JUDGMENT ON THE PLEADINGS BEFORE OLER, GUIDO, and MASLAND, JJ. ORDER OF COURT AND NOW, this 7`h day of October, 2011, pursuant to Plaintiff's Motion for Judgment on the Pleadings, and following oral argument on October 7, 2011, it is hereby ordered and directed that judgment is entered in favor of Plaintiff and against Defendant, Dewey Matthews, in the amount of $38,178.20, plus interest at the legal rate of 6% per annum from the date of the judgment. Philip Warholic, Esq. Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 Attorney for Plaintiff ? Dewey Matthews 5913 Crooked Creek Drive #D Manassas, VA 20112 Defendant, pro Se cop`e-S. oIto U tl :rc BY THE COURT, DIALYSIS CORPORATION OF : IN THE COURT OF COMMON PLEAS OF AMERICA d/b/a DCA OF CUMBERLAND COUNTY, PENNSYLVANIA CHEVY CHASE, : Plaintiff r"r, c;? r] :rm CIVIL ACTION-LAW S7 vs. NO. 10-3309 CIVIL: o ;-a DEWEY MATTHEWS, Defendant = era hJ ORDER - AND NOW, this 7- day of October, 2011, the appointment of a Board of Arbitrators in the above-captioned case is VACATED. Douglas Marcello, Esquire, Chairman, shall be paid the sum of $50.00. BY THE COURT, Kevin . Hess, P. J. Douglas Marcello, Esquire, ?r?'lar ee l1c a e; u; S,Fz, LLC. i nn wo /h,.? 4- 8,04-6-11 ", S ,3 3 Court Administrator COr 1, `s (,r, P14 Am ???c'S ??c?. ?? /D/arl// kz!