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HomeMy WebLinkAbout10-5279 tee" AUG 1z AM.9=40y Scott A. Dietterick, Esquire Supreme Court I.D. #55650 Kimberly A. Bonner, Esquire Supreme Court I.D. #89705 James, Smith, Dietterick & Connelly, LLP PO Box 650 Hershey, PA 17033 (717) 533-3280 (717) 533-2795 Attorneys for Plaintiff SURGICAL CARE AFFILIATES, LLC, T/D/B/A GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF V. YOLANDA MOURE, DEFENDANT 0u : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNA NO. fe m : CIVIL ACTION -LAW NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claim 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 plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR "a, 00'P 't 0.? rx K5.w-)3 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, PA 17013 (800) 990-9108 SURGICAL CARE AFFILIATES, LLC, T/D/B/A GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF V. YOLANDA MOURE, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNA . NO. : CIVIL ACTION - LAW AVISO USTED HA SIDO DEMONDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro do los proximos veinte (20) dias despues de la notifacacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comperencencia escrita y redicanco en la Courte por escrito sus defensas de, y objecciones a, los 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 reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero O propieded u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABAGADO IMMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO O NO PUEDE PAGARLE A UNO, LLAME A VAYA A LA SIGUEINTE OFICINA PARA AVERIGUAR DONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (800) 990-9108 Scott A. Dietterick, Esquire Supreme Court I.D. #55650 Kimberly A. Bonner, Esquire Supreme Court I.D. #89705 James, Smith, Dietterick & Connelly, LLP PO Box 650 Hershey, PA 17033 (717) 533-3280 (717) 533-2795 Attorneys for Plaintiff SURGICAL CARE AFFILIATES, LLC, T/D/B/A GRANDVIEW SURGERY & LASER CENTER, PLAINTIFF V. YOLANDA MOURE, DEFENDANT : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNA . NO. : CIVIL ACTION -LAW COMPLAINT The Plaintiff, Surgical Care Affiliates, LLC, t/d/b/a Grandview Surgery & Laser Center, by its attorneys, James, Smith, Dietterick & Connelly, LLP, hereby presents the following Complaint against the Defendant, Yolanda Moure, as follows: 1. Plaintiff, Surgical Care Affiliates, LLC, t/d/b/a Grandview Surgery & Laser Center (hereinafter referred to as "Grandview"), is an Alabama corporation, registered to do business in Pennsylvania, with its office located at 205 Grandview Avenue, Camp Hill, Cumberland County, Pennsylvania 17011. 2. Defendant, Yolanda Moure, is an adult individual, with her last known address at 312 S. Front Street, Apt, A, Lemoyne, Cumberland County, Pennsylvania 17043. COUNTI BREACH OF CONTRACT 3. Grandview incorporates Paragraphs 1 through 2 as if fully reproduced herein. 4. Grandview is a facility that performs same-day out-patient surgery to patients who desire same. 5. On July 9, 2009, Defendant arrived at Grandview for a left endoscopic carpal tunnel release. 6. When Defendant arrived at Grandview, it was confirmed that Defendant had health insurance through Regence Blue Shield of Idaho, to Policy #XNE080038868. 7. Defendant signed Grandview's Financial Agreement, Assignment of Benefits and Release of Records prior to her surgery. A copy of this Agreement is attached hereto and identified as Exhibit "A." 8. Grandview submitted its bill for services rendered, totaling $3,129.00 to Defendant's insurance company on or about July 10, 2009. 9. On July 23, 2009, Defendant arrived at Grandview for a right endoscopic carpal tunnel release. 10. When Defendant arrived at Grandview, it was confirmed that Defendant had health insurance through Regence Blue Shield of Idaho, to Policy #XNE080038868. 11. Defendant signed Grandview's Financial Agreement, Assignment of Benefits and Release of Records prior to her surgery. A copy of this Agreement is attached hereto and identified as Exhibit T." 12. Grandview submitted its bill for services rendered, totaling $3,129.00 to Defendant's insurance company on or about July 24, 2009. 13. On or about September 16 & 23, 2009, Grandview received notices from Defendant's insurance company that the claim was not being paid. 14. Grandview contacted Defendant's insurance company and was told that it was waiting for the Coordination of Benefits from the Defendant and the information that Defendant would provide was needed to process the two claims for payment. 15. According to the terms of Grandview's Financial Agreement, if accounts are forwarded for further collection efforts, Grandview is entitled to collection fees totaling 30% of the unpaid balance. 16. Collection fees incurred by Grandview total $1,877.40. 17. Defendant has continuously refused to make payment to Grandview for the balance due and otherwise ignored Plaintiffs demands for payment of same. WHEREFORE, Plaintiff, Surgical Care Affiliates, LLC, t/b/d/a Grandview Surgery & Laser Center, demands judgment against Defendant Yolanda Moure, in an amount not in excess of $50,000.00, which amount requires submission of this matter to compulsory arbitration. COUNT II UNJUST ENRICHMENT 18. Grandview incorporates Paragraphs 1 through 17 as is fully reproduced herein. 19. Grandview provided Defendant with medical services, as requested by Defendant, totaling $6,258.00; Grandview having done so to the benefit of Defendant; Defendant became liable for the just and reasonable amount of the surgery. 20. Defendant has been unjustly enriched by accepting the service of Grandview and not paying the total amount due for same. 21. Grandview has demanded that Defendant pay the total amount due of $8,135.40, but Defendant as refused to do so. WHEREFORE, Plaintiff, Surgical Care Affiliates, LLC, t/b/d/a Grandview Surgery & Laser Center, demands judgment against Defendant Yolanda Moure, in an amount not in excess of $50,000.00, which amount requires submission of this matter to compulsory arbitration. RESPECTFULLY SUBMITTED, JAMES, S IMITH, DIETTERICK & CONNELLY, LLP BY: 1 LAIA OOA Scott A. Dietterick, Lkiq Supreme Court I.D. #55650 Kimberly A. Bonner, Esquire Supreme Court I.D# 89705 James, Smith, Dietterick & Connelly, LLP PO Box 650/1-lershey, PA 17033 (717) 533-3280 (717) 533-2795 fax Attorneys for Plaintiff DATE: August 12, 2010 Surgical Care Affiliates DATE LAST NAME PHONE -412-789 SCASU NEED TO CALL WILL BE HERE ADDRESS STREET CITY COUNTY PO BOX 143 LEMOYNE PATATE 17043 PRIOR ADMIT SSN DRIVER LICENSE OCCUPATION 082-44-0206 WORKP 717-37 379-3780 RESPONSIBLE PARTY NAME AND ADDRESS IF DIFFERENT FROM. ABOVE SELF RELATION TO RESPONSIBLE PARTY RESPONSIBLE PARTY SSN RESPONSIBLE PARTY EMPLOYER PHONE SELF SAME RESPONSILE PARTY ODY BUII.DING.COM SAME PRMAARY INSURANCE COMPANY NAMEMNrIE OF INSURED SECONDARY INSURANCE COMPIWY NAMEMAME OF INSURED REGENCE BS OF ID (PPO) - MOURE, YOLANDA PO BOX 890173 CAMP HILL, PA 17011 I.D.1/SSN JGROUP t AUTHORIZATION I.D. #/SSN GROLIF XNE080038868 60007290 INSURED-SEMPLOYER AND PHONE DIAGNOSIS MD, STEPHEN W PROPOSED SURGERY (1) LEFT ENDOSCOPIC CARPAL TUNNEL RELEASE L. MI I DEPOSIT ATTACHMENT CI CWM# FINANCIAL AGREEMENT, ASSIGNMENT OF BENEFITS AND RELEASE OF RECORD(S) I hereby assign to and authorize payment directly to the facility nerved above (the 'facility's of all benefits due me under Medicare, Medicaid, or any insurance policy providing benefits for facility charges, for services rendered by the facility and anesthesia Provider as designated. A photostatic copy of this agreement shag be considered effective and valid as the original. I irrevocably agree that the facifdy may discloae, to the Well allowed by law, my medical and financial record to a Surgical Cane Affiliates and Its employees and agents, including entities under contract with same to ( provide l{rt ) andany /or aff utilizatW of bon the review; (ew, (y, b) specifically including which may be liable under contract or by law to the facility or to me, or any parson or entity e for all Or part of the any person or g any insurace company or their agents or employees; (c) any Person Or ? been refer by my charges, specifically including any physician treating, consulting or otherwise performing services for me, indudto whom I ing his r her employe by agents; thets {e) ; (a) facility the or by Centers my for physician Medicare for and continued Medicaid care; Servi rvi any arty other govemmwtai or accrediting agency, or their agents or employees. ces, All fae ty charges are due and owing at discharge. In consideration of the services to be rendered, to the extent not e the contract between the facility and my third party payor, I HEREBY AGREE, WHETHER I AM SIGNING AS PATIENT OR GUARANTOR, To PPsly AYYAALLL S IMS E low or THE FACILITY AT THE USUAL AND CUSTOMARY CHARGE OF THE FACILITY. I hereby waive all claims of exemption Should the account be referred to nn att for colleMon, I shall pay reasonable attorney's fees and collection atpenses omey or collection agency or days from the date of service) may bear Interest on the unpaid amount to the mawmum roam" allowed by low acursta and thaamounts t I am financially not pad within charges not paid within said 60 days and for charges not covered by this ass4rwrient. I understand that the facility files for reimbursement from my Insurer orr other payor as a courtesy, and failure on the part of the insurer to make payment shall not relieve me of my obligation to pay the facility. I certify that I am the patient or that I am financially responsible for the services rendered and do hereby unconditionally guaranty the payment of all amounts when and as due. Facility employees are NOT able to define your insurance coverage. If you have coverage questions, you are advised to call your insurance carrier. CAUTION: DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND ITS CONTENTS. DATE WfTN DATE DATE Patient Name and Arrival Time PLAINTIFF'S EXHIBIT Surgical Care Affiliates Patimt ID/Visit 2041 DATE TIME A T LAST NAME FIRST NAME MI A 2549 DEPOSIT CI YO ANDA MIF DOB AGE MSW HONE PHONE i - 00 CAST 7 ; RIDEIP M E F 10/24/54 154 717=412-7891 7 BE HERE ADDRESS STREET CM COUNTY PO BOX 143 LEMOYNE STATE LP PA . 17043 PRIOR ADMIT ISBN DRIVER LICENSE OCCUPATION 07/09/09 82-44-0206 WORK PHONE 717-379-3780 RESPONSIBLE PARTY NAME AND ADDRESS IF DIFFERENT FROM ABOVE SELF RELATION TO RESPONSIBLE FARTYJ RESPONSIBLE PARTY SSN RESPONSIBLE PARTY EMPLOYER SELF RESPONSIBLE PARTY PHONE SAME ODY BUILDING.COM SAME PRIMARY INSURANCE COMPANY NAMVNAME OF INSURED SECONDARY INSL ANCE COMPANY NAMHWAME of INSURED REGENCE BS OF ID (PPO) - MOURE, YOLANDA PO BOX 890173 CAMP HILL, PA 17011 I.D. //SSN GROUP 1 AUTHORIZATION X N E 080038868 1 60 007290 I.O. ASSN GROU P ? AUT'HOR2ATDN ?y p ? p p? , l3CJi7 ?V.LCJM INSURER'S EMPLOYER Am PHONE SURGEON' CLAM' ATTENTION 7POSED SURGERY -- (1) RIGHT ENDOSCOPIC CARPAL TUNNEL RELEASE; R. FINANCIAL AGREEMENT, ASSIGNMENT OF BENEFITS AND RELEASE OF RECORD(S) I hereby assign to and authorize payment directly to the factility named above (the "facility") of all benefits due me under Medicare, Medicaid, or any insurance policy providing benefits for facility charges, for services rendered by the facility and anesthesia provider as designated. A Photostatic copy of this agreement "I be considered effective and valid as the original. I Irrevocably agree that the facility may disclose, to the extent allowed by law, my medical and financial record to (a) any affiliate of the fae ty, specifically including Surgical Care Affiliates and Its employees and agents, including entities under contract with same to provide quality and/or utilization review, (b) any person or entity which may be liable under contract or by law to the fadGty or to me, or any person or entity responsible for all or insurance company or their agents or employees; (c) s person or ? part of the facility's charges ician for continued . for circa (inducing (g any physician treating, consulting or otherwise performing services for me, inducing ?his or I have been ralarratj by her employees and a ; the (9) facility the or by an Centers for Medicare for Madicsare and Medicaid Serv rviany any other govervnental or accrediting agency, or their agents or employees. (e) ces, All facility charges are due and owing at discharge. In consideration of the services to be rendered, to the extent not expressly prohibited by law or by the contract between the facility and my third party payor, I HEREBY AGREE, WHETHER I AM SIGNING AS PATIENT OR GUARANTOR, TO PAY ALL SUMS DUE THE FACILITY AT THE, USUAL AND CUSTOMARY CHARGE OF THE FACILITY. I hereby waive all claims of exemption. Should the account be referred to an attorney or collection agency for collection, I shall pay reasonable attorney's fees and collection expenses whether suit Is filed or not. Dainngoent accounts and mounts (those not paid within 60 days from the date of service) may bear interest on the unpaid amount up to the maxlmun amount allowed by low. I understand that I am financially charges not paid within said 60 days and for charges not covered by this assignment. I understand that the facility files for reimbursement from my Insurer or oethefor r payoris a courtesy, and fallure on the part of the insurer to make payment shall not relieve me of my obligation to pay the fadlft)k I certify that 1 am the patient or that I am financially responsble for the services rendered and do hereby uncorldrtionelly guaranty the payment of a8 arnwits when and as due Facility employees are NOT able to define your insurance coverage. If you have coverage questions, yotrare advised to call your insurance carrier: CAUTION: DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND ITS CONTENTS. DATE Zeennt Name and Arrival Time PLAIN Uf EXHIBIT 12- SURGICAL CARE AFFILIATES, : IN THE COURT OF COMMON PLEAS LLC, T/D/B/A GRANDVIEW : CUMBERLAND COUNTY, PENNA SURGERY & LASER CENTER, PLAINTIFF V. . NO. YOLANDA MOURE, DEFENDANT CIVIL ACTION - LAW VERIFICATION I, Shelly Sollazzi, Business Office Manager of Surgical Care Affiliates, LLC, t/d/b/a Grandview & Laser Center, hereby verify the facts contained in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. SH Y S I DATE: F- I1-(6 SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny R Anderson Sheriff ~garrtr of ~it~~brr~~~d ~; . ,~ caFrfcE - `~~ ~ ~RirF ~~~3AP~Y 10A1163i AM 8: 35 Jody S Smith Chief Deputy Richard W Stewart Solicitor q,~g.t-tva: V~~ '~~~~Y4 Surgical Care Affiliates, LLC vs. Yolanda Moure Case Number 2010-5279 SHERIFF'S RETURN OF SERVICE 08/20!2010 07:33 PM -Gerald Worthington, Deputy Sheriff, who being duly sworn according to law, states that on August 20, 2010 at 1933 hours, he served a true copy of the within Complaint and Notice, upon the within named defendant, to wit: Yolanda Moure, by making known unto herself personally, at 306 South Front Street, Rear, Second Floor, Wormleysburg, Cumberland County, Pennsylvania 17043 its contents and at the same time handing to her personally the said true and correct copy of the same. SHERIFF COST: $57.24 August 26, 2010 GE LD WORTHINGT ,DEPUTY SO ANSWERS, y RON R ANDERSON, SHERIFF (cj CountySuite Sheriff. Teleosoft, Inc.