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HomeMy WebLinkAbout11-3593The Estate of Lois J. Summers, C ? IN THE COURT OF COMMON PS ' PENNS)*V WNI* CUMBERLAND COUNTY r??1rr , CD CD NO. twz CIVIL ACTION - PETITION TO SETTLE WRONGFUL DEATH AND SURVIVAL CLAIMS UNDER 42 Pa. C.S.A. & 2206 740 AND NOW, this z? day of L, 2011, comes the Plaintiff, Joan L. Stoufer, Z Executrix of the Estate of the late Lois J. Summers, by and through her attorney, Joseph J. Dixon, Esquire, who respectfully requests this Honorable Court approve settlement of death claims concerning the Estate of the late Lois J. Summers. On January 18, 2010 the late Lois A. Summers was in a motor vehicle accident at a parking lot in Hanover, Pennsylvania. 2. At said time and place, the late Lois A. Summers was exiting the motor vehicle when the driver of the motor vehicle began to drive away. The driver of the motor vehicle was Janet M. Lohr. 3. After the motor vehicle accident, the late Lois J. Summers suffered personal injuries and complications from the injuries which ultimately led to her death on May 12, 2010. (See copy of Summary Medical Report from Dr. Francis X. Brescia, Jr. attached hereto and marked Exhibit A, which explains and summarizes the late Lois J. Summers medical condition from January 18, 2010 through her death on May 12, 2010.) *q,;,00 PQ ATty e# 0 a5783q 4. On March 1, 2010, the late Lois J. Summers, through her Power of Attorney, entered into an Attorney's Fee Agreement with Joseph J. Dixon, Esquire, to handle the personal injury case resulting from the motor vehicle accident described in this Petition. (See copy of Agreement of March 1, 2010 attached hereto and marked Exhibit B.) 5. Unfortunately, Lois J. Summers passed away from complications from the injuries sustained in the motor vehicle accident on May 12, 2010. 6. On May 20, 2010 the Honorable Glenda Farner Strasbaugh, Register of Wills of Cumberland County, issued Letters of Testamentary for the Estate to your Petitioner Joan L. Stoufer. (See copy of Short Certificate attached hereto and marked Exhibit C.) 7. After the institution of the Estate on May 21, 2010, the Estate executed a Fee Agreement with Joseph J. Dixon, Esquire, for representation on this matter. (See copy of Fee Agreement attached hereto and marked Exhibit D.) 8. Thereafter, Counsel for the late Lois J. Summers entered into negotiations with Erie Insurance Company, the liability carrier for the driver of the motor vehicle that injured Ms. Summers. 9. After extensive negotiations, on January 31, 2011, Erie Insurance Company tendered their policy limits of Three Hundred Thousand Dollars ($300,000.00) to resolve their portion of this death claim. (See copy of offer and verification of coverage attached hereto and marked Exhibit E.) It was not necessary to file a formal suit to secure this resolution. 10. Pursuant to the resolution of the liability portion of the claim, Joan L. Stoufer, Executrix of the Estate, executed a Settlement Sheet resolving the claim with Erie Insurance Company and resulting in a net amount to the Estate of Lois J. Summers of $222,964.16. (See copy of Settlement Sheet attached hereto and marked Exhibit F.) 11. At the time of her decease, the late Lois J. Summers had $100,000.00 in medical payment coverage and $1,000,000.00 in excess medical payment coverage. These coverages preclude any of the medical bills being paid by Medicare. (See copy of letter of February 7, 2011 from Susan McFarland of Nationwide Insurance Company attached hereto and marked Exhibit G.) 12. Hereafter, the Estate of Lois J. Summers, through counsel initiated negotiations with Nationwide Insurance Company to resolve the underinsured portion of the claim. The underinsured policy limits were $100,000.00. (See copy of Email from Chris Rudai of Nationwide Insurance Company attached hereto and marked Exhibit H.) 13. After negotiations, the Estate of the late Lois J. Summers has agreed to resolve the underinsured portion of this claim for $75,000.00. Nationwide Insurance Company has for- warded a Release and Email concerning this resolution. (See Email and proposed release from Nationwide Insurance Company, Adjustor Chris Rudai, attached hereto and marked Exhibit I.) 14. Counsel for the Estate on the settlement , Joseph J. Dixon, Esquire, feels that the settlement is fair and reasonable under all circumstances regarding the case. (See Affidavit of Joseph J. Dixon, Esquire attached hereto and marked Exhibit J.) 15. Out of the remaining $75,000.00 received from Nationwide Insurance Company, the Estate will receive an additional net of $56,250.00. (See proposed Settlement Sheet attached hereto on the underinsured portion of the claim and marked Exhibit K.) 16. Counsel for the Estate of the late Lois J. Summers, Shelly Kunkle joins in the prayer of this Petition. (See Joinder attached hereto and marked Exhibit L.) WHEREFORE, the Petitioner respectfully requests this Honorable Court to enter a Court Order approving the settlement and distributions. Respectfully submitted, By:11 Joseph J. Dixon, Esquire Attorney ID 28290 126 State Street Harrisburg, PA 17101 (717) 236-8515 Attorney for the Plaintiff Dated: EXHIBIT A FRANCIS X. BRESCIA JR., D.O. FACOFP Family Physician October 15, 2010 Joseph J. Dixon Attorney at Law 126 State Street Harrisburg, PA 17101 Dear Attorney Dixon: You have asked me to do a paper review of the medical records of the late Lois J. Summers. I have reviewed 'all of the records you have provided to me and I would be glad to give you a summary and opinion as to what happened in this case. I have reviewed the following charts: (1) Hanover Hospital, (2) Holy Spirit Hospital, (3) Harrisburg Hospital, (4) Golden Living Rehabilitation Center, (5) Health South Rehabilitation, (6) Community General Osteopathic Hospital, (7) The Jewish Home, (8) Hershey Medical Center and (9) Pennsylvania Psychiatric Institute.. From these records 1 have learned that Ms. Lois J. Summers was injured on January 18, 2010, in a motor vehicle accident. At that time she was exiting a motor vehicle when the driver drove off leaving half of her body still in the vehicle. Ms. Summers suffered two fractures of the right ankle and soft tissue injuries to the right shoulder. She was admitted to Hanover Hospital Emergency Room for emergency care but then requested to be transferred to Holy Spirit Hospital due to the closeness of the hospital to her home. At the time of her transfer to Holy Spirit Hospital, her blood pressure was 120/70, well within normal limits and the patient had no complaints except for severe discomfort and pain. It is important to note that when she was admitted to Holy Spirit Hospital the only diagnoses listed in her past history were hypertension, glaucoma, and hearing difficulties. Her past surgeries include cataracts and a total right knee replacement. The history given to the nurses and social workers indicated that she was 82 years old, was born in Steelton, Pennsylvania, graduated high school and was an accountant for a moving company for her work and career. She never married and lived independently and was active in activities of daily living up until the time of the accident. it was first noted at Holy Spirit Hospital that she had some depression from the circumstances she was in from the injuries from the accident. When she was discharged from Holy Spirit Hospital, it was the requirement of the orthopedic doctors that she have non-weight bearing rehabilitation. As a result, she was transferred to the Golden Living Rehabilitation Center on January 21, 2010, for a 6-9 week course of rehabilitation. It should be noted that she was in severe pain and was given among other prescriptions, Percocet 5-325 mg two tablets four times a day for this pain. During her transfer to the Golden Living Rehab Center she unfortunately developed a urinary tract infection, and it was complicated more by developing a C Diff infection causing severe diarrhea and abdominal pain. She also injured her left leg while being transferred from the bed 712 Allegheny Street, Daaphin,'% 17018 = h 717-921=2361 Fx: 717-921-3345 - dauphinoffice@comcast.net while at that facility. These types of complications unfortunately happen with elderly individuals who are non-weight bearing and are going through other severe trauma such as the injuries sustained by Ms. Summers. Obviously, these complications were frustrating to Ms. Summers and affected her both physically and psychologically. On March 02, 2010, Ms. Summers was transferred to Health South Rehabilitation Center for acute rehab under the care of Dr. Michael Lupinacci. She was also followed by the Internists of Central Pennsylvania because the C Diff infection continued. She underwent multiple courses of antibiotics, Celexa was prescribed for depression and Risperdal for agitation. It is important to note at that time, Dr. Lisa Eaton, a clinical neurophysiologist evaluated Lois as having, in addition to the above physical problems, adjustment disorder with mixed features of depression and anxiety secondary to medical and physical stressors, symptoms of agitation, and possible hallucinations reported. The records show that in addition to the C Diff and orthopedic problems, she suffered from persistent diarrhea which was demoralizing to her. Nevertheless, she had the goal of getting back home and she continued her rehabilitation and was discharged to her home with twenty-four hour a day nurses on March 23, 2010. Lois was under the care of her family physician, Dr. William Wewer during this period. Ms. Summers only lasted two days at home because she was unable to walk unassisted and unable to go to the bathroom without assistance from three people. Unfortunately on March 25, 2010, rectal bleeding commenced again and Dr. William Wewer had her transported by ambulance to Community General Osteopathic Hospital. At this point in time, both Ms. Summers' physical health and mental health deteriorated at a much more rapid pace. The McLaughlin Gastroenterology Group performed a colonoscopy on March 29, 2010, to reevaluate the rectal bleeding from the C Diff infection. Ms. Summers became verbally abusive, uncooperative, and combative and the Coumadin was discontinued due to the severity of the rectal bleeding. She was still taking Vancomycin, Celexa, and Risperdal. On April 01, 2010, she was admitted to the Jewish Home from Community General Osteopathic Hospital via ambulance. During this admission she continued to suffer from swelling in her legs. She did fall out of bed and continued to be very combative. Several times she was found confused on the floor at the Jewish Home. Lasix was introduced to decrease the swelling in Ms. Summers' legs that were openly leaking large amounts of fluid onto the floor wherever Ms. Summers was located. She was sent back to the emergency room at Community General Osteopathic Hospital on April 05, 2010, for treatment of lymphedema in both legs. She was then sent back to the Jewish Home but the combativeness and agitation continued and she was then transferred to Penn State Milton Hershey Medical Center. She was treated and evaluated at that time with her mental condition severely deteriorated and she was referred to the Pennsylvania Psychiatric Institute at the Polyclinic Campus on April 08, 2010. At that hospital stay she was treated for lymphedema of her lower extremities and mental health issues. Five days later she was transferred to Harrisburg Hospital and received blood transfusions on April 13, 2010, due to low hematocrit secondary to her rectal bleeding. She was then admitted to Harrisburg Hospital on April 18, 2010, and stayed there until her death on May 12, 2010. During that hospital stay her systems began to shut down, she underwent kidney failure and had her entire colon removed in a heroic attempt by the doctors to save her life. Unfortunately, she passed away on May 12, 2010. After reviewing all of the medical information provided, I feel that the medical care received by Ms. Summers from the date of the injury through the date of her death was superb and well within the medical community. It is an unfortunate situation, however, when a motor vehicle accident causes a severe injury to a senior citizen and severe complications do occur. These complications are all within a reasonable degree of medical certainty related to the motor vehicle accident of January 18, 2010. This includes both the physical health complications and mental health complications set forth in the records. I would comment concerning the mental health deterioration that the psychologists involved have described very clearly the fact that the mental health deterioration was caused by the motor vehicle accident and the confinement that was necessary for treatment of the motor vehicle accident. I believe the deterioration is commonly called in layman's terms hospital delirium. This unfortunate condition does occur and unquestionably affects the health of the senior citizen throughout the medical treatment process. In addition, after reviewing the voluminous records you have sent me, it is obvious that on a daily basis Ms. Summers suffered from severe physical pain from the motor vehicle accident and complications from it. In addition to the physical pain, the mental anguish was overwhelming. The records show that she lost control of her independent life and was humiliated by problems such as infection and diarrhea. Despite her deteriorating mental condition and agitation she was displaying, there are records that show she understood what was going on and she knew that she was gradually dying. Please contact me if you desire any additional clarification on this sad case. Sincerely, _ I?V Franci X. es , Jr., D.O., FACOFP FXB/dmc XV/ EXHIBIT B JOSEPH J. DIXON Attorney At Law 126 State Street Harrisburg, Pennsylvania 17101 (717) 236-8515 (717) 233-5860 (telefax) POWER OF ATTORNEY AND CONTINGENT FEE AGREEMENT I/We, the undersigned, ?. r? t y V rµ n? V"j ..do hereby irrevocably appoint JOSEPH J. DIXON, ESQUIRE, my attorney with respect to a cause of action arising out of ?y fd -.r G a4" 1 ?? Lf 0 with full power to make inquiries, to negotiate or settle, bring, conduct, prosecute, sue or compromise any action or suit, and to execute and endorse any papers, checks or orders on my/our behalf in connection therewith. For his services, said Attorney shall be entitled to a contingent fee from any recovery made or secured of twenty-five (25%) percent; thirty-three (33%) percent in the event suit is filed; and forty (40%) percent in the event of trial or if settlement is reached within thirty (30) days of trial. Costs, filing fees and expenses, other than attorney fees, shall be paid by: ?. n S .T Sri ?M ? % S Witness my/our hand(s) and seal(s) this day of k4rrri 2010 (SEAL) (SEAL) (SEAL) The above appointment and agreement are hereby approved and accepted this f dayof_ MAire.(i ,201 . EXHIBIT C .dun, 4. 2010 2:59PM WION, ZULLI, & SEIBERT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND y No. 3597 P, 2 SHORT CERTIFICATE I, GLENDA FARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 20th day of May, Two Thousand and Ten, Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of LOTS J SUMMERS late of NEW CUMBERLAND BOROUGH lh7rab Mww, Low in said county, deceased, to JOAN L STOUFER !First, Middle, Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLB, PRNNSYL'VANTA, this 20th day of May Two Thousand and Ten. File No. 2010-00531 PA Pi l e No. 21-10-0531 Date of Death 511212010 S . S . # 162-22-6792 AMAIA) ,-'?AdAAAA- Jj11A.41AA11A1,') Peg- ter r !S h Deputy NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL EXHIBIT D C/ zV , . ! r ::{ ! "',A r , rya 5at?o cd Z 002/002 (717) 236-8515 I/We, the undersign( WOW JOSEPH J. DIXON, of ?xa?rtd'c?1?i? ?' Lodes do hereby irrevocably with respect to a cause of action arising out . /.., - with full power to make inquiries, to negotiate or settle, bring, conduct, prosecute, sue or compromise any action or suit, and to execute and endorse any papers, checks or orders on my/our behalf in connection therewith. For his services, said Attorney shall be entitled to a contingent fee from any recovery made or secured of twenty-five (25%) percent; thirty, three (33%) percent in the event suit is filed; and forty (40%) percent in the event of trial or if settlement is reached within thirty days of trial. Costs, filin fees and expenses, other than, attorney fees, shall be paid by(30) 7 ,0"4 or v q`r Witness my/our hand(s) and seal(s) this o2 /s+ da of 201 a Y (SEAT) (SEAL) (SEAL) The above appointment and agreement are hereby approved and accepted this day of , 201j_. JOSEPI1 J. DxXON Attorney At Law 126 State Street Harrisburg, Pennsylvania 17101 (717) 233-5860 (telefax) T A.... Bo oseph J. bixon, Esq EXHIBIT E 02/01/2011 1713 FAX 7177952315 KIN F41t V Erie J Insurance' k 4 Branch Office • 4901 Louise Dr, - Posemoyne Businees Censer - P.O, Box 2013 - MerhanirsbUrg, PA 17055.0710 717.795.6200 , Toll irao 1.800.382,1304 , Fax 717.796.2315 - www,erialneurance, corn January 31, 2011 Joseph Dixon, Esq. 126 State Street Harrisburg, PA 17101.1026 Re: ERIE Claim 4010171073747 ERIE Insured: Janet M. Lohr Date of Loss: 1/18/10 Your Client: Lois Summer Dear Mr. Dixon: 1a002/004 This letter is being sent as follow up of our telephone conversation this date, January 31, 2011, regarding settlement of the Bodily Injury Liability claim regarding the estatc of Lois Summer. Erie Insurance agrees to tender our Bodily Injury Liability limits in the amount of $300,000, 00 a settlement of this claim. Herein enclosed, please find the ERIE settlement Release which will need to be signed and notarized. In order for Erie Insurance to issue the settlement check, we do require some additional information, Please provide a detailed letter from Nationwide Insurance Company confirming that the First Party Medical coverage under their Claim #58378428557 has reimbursed all medical bills regarding Lois Summer; specifically, from the date of this accident, January 18, 2010, up until Ms, Summer's death on May 12, 2010. It is important that the First Party Medical a!, uster be specific that there are no pending Medicare liens, as Ms. Summer had not only the $100,000,00 First party coverage, but she also had an extraordinary policy of $1,000,000,00, Erie Insurance will also require from the Nationwide Underinsured Motorists claims adjuster to provide a Consent to Settlement and Waiver of Subrogation in regard to this matter. When returning the above-requested documentation, please provide your firm's Tax Id Number for issuance of the check and specific instructions on how you would like the check to be issued, Should you have any further questions regarding this matter, please contact the undersigned at (717) 652.1024. Sincerely, Lori Renaldi-Wagar Liability Claims Adjuster Harrisburg Branch Claims (717) 795-2315 (Fax) LR: sab Enclosure: Settlement Release 20209761, DOC 02/01/2011 17:13 FAX 7177952315 1a004/004 01/01/2006 01:09 7176521045 LORIRENALDIWAUAR PAGE 03/04 Law ERIE INSURANCE EXCHANGE FAMILY AUTO POLICY CONTINUATION NOTICE AA7646 FETROW ZNS ASSOC LLC JANET M LOHR 157 PEACE CIRCLE NEW OXFORD PA 17350-7300 01/12/10 TO 01/12/11 Q01 1202589 x AS LISTED BELOW AGENT - FETROW INS ASSOC LLC 5299 E. TRINDLE RD. **+** AGENT PHONE - (717) 766-3200 MECHANICSBURG PA 17050 3552 * CONGRATULATIONS: A PIONEER EXBERIENCE RATING CREDIT HAS w BEEN APPLIED TO YOUR POLICX PREMIUM. L4******************w**************t+****************i.6 ***}***w*********a**}}? 'YOUR COLLISION COVERAGE AND DEDUCTIBLE APPLY TO PRIVATE PASSENGER " * AUTOS YOU OR A RESIDENT RELATIVE RENT FOR 45 DAYS OR LESS. THIS IS * SUBJECT TO LIMITS, TERMS AND CONDITIONS IN THE POLICY. " k***+********************•********+*****************}*******M***********i**t}* ITEM 4. AUTOS COVERED AUTO YR MAKE VIN ST TER FEY LIOTCMCL RATINGCLASS DDP 1 06 LEXU RX 330 AWD 2T2HA31UX6C096328 PA IF N 0807 ALAS F986 2 07 GEM CAR ES 5A5AJ274X7F044726 PA 1P K4 ITEM 5, INSURANCE IS PROVIDED WHERE A PREMIUM, OR INCL, IS SHOWN FOR THE COVERAGE. COVERAGES, LIMITS AND ANNUAL PREMIUMS ARE AS FOLLOWS- M EQUALS THOUSAND $ 01 42 *****GOOD DRIVER RATES APPLY***** --- THE FULL TORT OPTION APPLIES TO ALL PRIVATE PASSENGER VEHICLES- LIABILITY PROTECTION- BODILY INJURY $30014/PERSON $300M/ACC PROPERTY DAMAGE $100M/ACC FIRST PARTY BENEFITS- MEDICAL EXPENSE $25M FUNERAL BENEFIT ?2.5M UNINSURED MOTORISTS COVERAGE- BCD INJ $300M/PERSON $300M/ACC^UNSTACKED UNDERINSURED MOTORISTS COVERAGE- SOD INJ $300N/PERSON $30CM/ACC-UNSTACKED PHYSICAL DAMAGE COVERAGES- COMPREHENSIVE - $100 DED COLLISION - $100 DED COLLISION - $200 DED OPTIONAL COVERAGES- TRANSP EXPENSES - COMP $25/DAY, $1125/LOSS EXHIBIT F c??G1t?P?L4' ?1G?017i ATTORNEY AT LAW 126 STATE STREET • HARRISBURG, PA 17101 PHONE: (717) 233-8757 • FAX: (717) 233-5860 EMAIL: dixonlaw@paonline.com www.jdixonlaw.com SETTLEMENT SHEET OF ESTATE OF LOIS SUMMERS vs. JANET M. LOHR Date of Accident: January 18, 2010 Gross Check from Erie Insurance Company .............................. $ 300,000.00 Less Attorney Fee of Twenty-Five Per Cent ................................ $ 75,000.00 to Joseph J. Dixon, Esquire Less Expenses for Medical Records 03/18/10 Hanover Hospital $ 36.69 07/28/10 Record Reproduction Services 34.50 07/30/10 Record Reproduction Services 34.20 07/30/10 Star-Med 139.79 08/02/10 Star-Med 420.11 08/20/10 Nephrology Assoc. of Central PA 23.66 08/20/10 Star-Med 57.65 08/30/10 Healthport 68.02 09/09/10 Record Reproduction Services 92.87 09/14/10 Record Reproduction Services 92.87 09/21/10 State Street Copy 421.38 09/22/10 State Street Copy 63.54 10/07/10 Star-Med 184.49 10/07/10 Capital Delivery Systems 21.00 10115110 Healthport 91.41 10115110 Healthport 32.31 10115110 Family Practice Center 97.01 10/18/10 Healthport 103.34 10/21/10 Capital Delivery Systems 21.00 TOTAL EXPENSES $ 2,035.84 Total Amount Due to the Estate of Lois Summers ........................... $ 222,964.16 I, Joan L. Stoufer, agree with the above settlement of the late Lois Summers insurance claim against Erie Insurance Company. I will receive tomorrow a check in the amount of Two Hundred and Twenty-Two Thousand, Nine Hundred and Sixty-Four Dollars and Sixteen Cents ($ 222,964.16), in settlement of the claim against Erie Insurance Company. Date: t r 5 2 ©I ; //L/" ef/? Joan L. Stoufer C EXHIBIT G Nationwide Insurance Allied insurance Nationwide Agribusiness Titan Insurance On YourSide' Victoria Insurance PO Box 2655 * Harrisburg, PA 17105-9971 * * February 7, 2011 Joseph J. Dixon 126 State Street Harrisburg, PA 17101 OUR INSURED : The Estate of Lois J Summers OUR CLAIM NUMBER : 58 37 B 428557 01182010 01 DATE OF LOSS : 01-18-2010 Dear Mr. Dixon: Pursuant to your request, please be advised that Lois Summer has an excess medical benefit of $1,000,000.00. Our liability to one person in one accident is $50,000.00 per year. Subject to this limit for any one person in any one year, our aggregate limit for any one person is one million dollars for any one accident. During the first eighteen months of eligibility, we shall approve payments for the insured without regard to the $50,000.00 per year limit. For purposes of this option, the first 18 months of eligibility begins when the insured has incurred $100,000.00 of eligible necessary medical treatment and rehabilitative service expenses. To date, Nationwide has paid $100,000,00 under the first party benefit for Ms. Summers and $19.514.60 under the excess medical benefit. If there are outstanding medical bills related to the injuries from the motor vehicle accident from January 18, 2010 through the date of the death of Ms. Summers that were paid by Medicare, these bills could be eligible under the excess medical benefit up to the limits of the policy. Sincerely, Susan McFarlane(PA-02-23) Claims Department Nationwide Mutual Insurance Company (717)657-6955 Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. EXHIBIT H Read. Mail - d.ixonlaw@paonline.com Page 1 of 1 dixonlaw@paonline.com Account Options... Languages... - Menu View Mail Compose Search Calendar Help Log Off Go Back I Prev I Next I Reply I Reply All I Forward I Delete I Move To Deleted Message: 7 of 17 Printable Version From: RUDADI@nationwide.com Save Address I Headers To: dixonlaw@paonline.com CC: Date: Mon, 7 Mar 2011 15:11:26 -0500 Subject: Estate of Lois Summers Dear Mr. Dixon: As you know, I am handling the UI claim for the Estate of Lois Summers. As we discussed, the dec sheet for this policy shows Ul coverage limits of 100,000 per person/ 300,000 per accident non-stacked with one (1) listed vehicle. When I complete my review of the medical records you provided for your clients estate, I will follow up. Should you have any questions or concerns in the mean time, please feel free to contact me. Thanks and have a nice evening. Chris Rudai Special Claims Representative Nationwide Insurance NESRO Class Claims One Nationwide Gateway, Dept 5867 Des Moines, IA 50391-5867 Phone: (610) 234-2912 Fax: (866) 249-0043 Go Back I Prev I Next I Reply I Reply All I Forward I Delete I Move To Deleted oft 1. a-- 'r Classic WebMail Contact Webmail Support http://mail.paonline.con/X386ac89e939e929acc9ec8414c4flrmail.4035.cgi?&mbx=Main&... 3/7/2011 EXHIBIT I 'rint From: RUDAIJ1@nationwide.com ro: dixonlaw@paonline.com CC: Date: Mon, 4 Apr 2011 09:30:31 -0400 Subject: Estate of Summers Page 1 of Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. One Nationwide Gateway Dept. 5867 * Des Moines, IA 50391-5867 * April 4, 2011 Joseph J. Dixon 126 State Street Harrisburg, PA. 17101 OUR INSURED : The Estate of Lois J Summers OUR CLAIM NUMBER: 58 37 B 428557 01182010 01 YOUR CLIENT: The Estate of Lois J Summers DATE OF LOSS : 01-18-2010 Dear Mr. Dixon: The enclosed Underinsured Motorist (UI) Release confirms our settlement with your client's estate. Please have the administratix Of the estate read the form carefully and sign where indicated. The release must be signed by the administratix of the estate and witnessed by two others in the presence of a Notary Public. I will also need confirmation that the court has granted approval of the settlement in this matter. Additionally, I am enclosing sample copies of Nationwide's Medicare addendum. Please choose the most appropriate form and have the administratix of the estate sign where indicated. Please return the completed release and petition granting court approval to my attention via email at rudaij1@nationwide.com, or fax to (866) 249-0043. Should you have any questions or concerns, please feel free to contact me. Thank you. Sincerely, Chris Rudai Claims Department Nationwide Mutual Insurance Company Voice: (610) 234-2912 Fax: (866) 249-0043 Email: rudaij@nationwide.com Enclosures Addendum A (no Medicare involvement).5.30.09.doc (Binary attachment) Addendum E (------ nNoCondFutPaymentsNoMSA).5.30 - .09.doc (Binary attachment) ------------- -------- Addendum F(M_edBenCond&FutPaymentsNoMSA) doc (Binary attachment) Scan001.pdf (Binary attachment) "RELEASE" UNDERINSURED MOTORIST COVERAGE Know all men by these presents: That, for the sole consideration of the sum of Seventy-Five-Thousand Dollars ($75,000.00), the receipt of which from the Nationwide Mutual Insurance Company (hereinafter called "Nationwide") is hereby acknowledged, the undersigned hereby releases, discharges, and for his/her self, his/her executors, administrators, successors and assigns, does forever release and discharge Nationwide of and from all claims, past and present, arising out of the Underinsured Motorist Coverage of an Automobile Insurance Policy number 428557 issued by Nationwide to The Estate of Lois J Summers, and resulting or to result from an accident which occurred on 01-18-2010 at or near Ryan's Restaurant: Hanover, Pennsylvania. This release constitutes permission from Nationwide to the insured to settle with the Underinsured Motorist, and contains the ENTIRE AGREEMENT of the parties hereto, and the terms of this release are contractual and not merely a recital. The undersigneds are responsible for payment of any outstanding medical liens and will indemnify and hold Nationwide harmless from any such liens. I/We further state that I/we have carefully read the foregoing release and know the contents thereof, and I/we sign the same as my/our own free act. WITNESS / Hand and seal this day of 20 In the presence of: CAUTION! READ BEFORE SIGNING Witness Signaturer"6e-)_ Your Signatur Witness Signatures a i?r (11Ai«,rris'r?,r?i Your Signatures K$7A?7C -'/p(t}plk. Pjtt NT' <<,<•MINf -1•YA'/1 '7rK d)?- C!S7rt?E•-/?iu; i?CP S/G ?, State of County of On this day of 20 Before me personally appeared , to me known to be the person... described herein, and who executed the foregoing instrument and he/she acknowledged that he/she voluntarily executed the same. My term expires 20 Notary Public CLAIM NUMBER: 58 37 B 428557 01182010 01 Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. ADDENDUM TO RELEASE OF ALL CLAIMS (Probable Medicare Beneficiary No Conditional Payments, Probable Future Treatment, MSA Refused) I, CLAIMANT'S NAME, (hereinafter also referred to as "I" or "Claimant"), individually and on behalf of my heirs, executors, administrators and assigns, as further consideration for the settlement referenced in the RELEASE OF ALL CLAIMS, further recite, warrant, and agree to and warrant the following: DISCLOSURES, WARRANTIES AND INDEMNITY AGREEMENT 1. Recitations and Disclosures I understand that in reaching this agreement, the parties have given considerable attention to, whether the Claimant is entitled to Social Security disability benefits pursuant to 42 U.S.C. § 423. It is not the intention of any party to this settlement to shift to Medicare or responsibility for payment of medical expenses for the treatment of injuries sustained as result of the Accident. However, this settlement agreement is intended to foreclose the Released Parties responsibility for future payments of any medical expenses and prescription expenses related to that Accident. I understand that Section 1862(b)(2)(A)(ii) of the Social Security Act precludes Medicare payment for services to the extent that payment has been made or can reasonably be expected to be made promptly under liability insurance. 42 CFR 411.50 defines liability insurance. Anytime a settlement, judgment or award provides funds for future medical services, it can reasonably be expected that those funds are available to pay for future services related to what was claimed and/or released in the settlement, judgment, or award. Thus, Medicare should not be billed for future services until those funds are exhausted by payments to providers that would otherwise be covered by Medicare. I understand and agree that I am aware that, in 2007, the Medicare, Medicaid and SCHIP Extension Act (hereinafter "Extension Act") was passed and was enacted, in part, to protect Medicare when the settlement of a bodily injury claim involves the release of all future claims and the alleged injured individual is either a current Medicare beneficiary or has the potential to be entitled to Medicare benefits within thirty (30) months of the date of settlement. Furthermore, I understand that this Act requires the Carrier for the Released Parties to report all such settlements within a time established by the Secretary of Health and Human Services. The Released Parties have expressly denied all liability for any damages as a result of the Accident and dispute the reasonableness and necessity of past and future medical treatment and expenses allegedly incurred as a result of said Accident. Additionally, I understand that though the Released Parties dispute the reasonableness and necessity of future medical and prescription expenses related to the Accident, the medical and physician records allege that future medical and prescription expense will be incurred. In order protect the interests of Medicare as to these alleged future expenses, the Released Parties, by and through the Carrier, have offered to pay to the Claimant _ INSERT -SPELLED OUT MSA AMOUNT ($#,###) out of total amount of the consideration indicated in the RELEASE OF ALL CLAIMS to be placed in a Medicare "Set Aside Account" or Annuity, in order to comply with the Extension Act. I hereby expressly reject the Carrier's proposed set aside of funds into Medicare Set Aside Account or "Structured Settlement" Annuity. I understand that, if Medicare is not protected as set forth in the Extension Act, Medicare may cease all benefits otherwise available to me. I further understand and agree that, in the event Medicare seeks reimbursement for past or future payments, the Indemnity Agreement provides that I will indemnify the Released Parties from all responsibility for Medicare's claim. I further understand and agree that, in the event Medicare seeks reimbursement for future payments because of my elected failure to "set aside" a portion of these settlement monies, my personal assets may be used to satisfy the claims of Medicare. I further understand and agree that I may not sell, convey or otherwise encumber these personal assets to any other person or entity to avoid the appearance of having no personal assets. H. Warranties Therefore, in consideration of the parties' willingness to settle the claim referenced in the RELEASE OF ALL CLAIMS, and to induce said settlement, Claimant makes the following warranties: ¦ I am a Medicare beneficiary or have a reasonable expectation of becoming one in the next 30 months because (INSERT REASON HERE). ¦ My Social Security Number or Medicare Health Insurance Claim Number is (INSERT APPROPRIATE NUMBER HERE). ¦ Medicare has made NO CONDITIONAL PAYMENTS for any medical expense or prescription drug expense related to the Accident. ¦ No medical expense or prescription drug expense related to the Accident has been or will be submitted to Medicare for payment. ¦ I have disclosed to the Carrier the names of all medical providers which provided treatment for the injuries I sustained in the Accident. ¦ The Carrier for the Released Parties has proposed that (INSERT AMOUNT OF PROPOSED SET ASIDE) of the total settlement amount be put in a Medicare Set- Aside Account or an Annuity in an effort to comply fully with the Extension Act. ¦ I have expressly rejected this proposal. ¦ Should future medical treatment related to the "Accident" be required, the expense associated with that treatment will be paid from the proceeds of this settlement. ¦ No further medical expense or prescription drug expense related to the treatment I have received or will receive in the future related to the "Accident" will be submitted to Medicare for payment. ¦ No liens, including but not limited to liens for medical treatment by hospitals, physicians, or medical providers of any kind have been filed for the treatment of injuries sustained in the Accident. III. Hold Harmless and Indemnity Agreement Additionally, as further consideration of the parties' willingness to settle the claim referenced in the RELEASE OF ALL.CLAIMS, and to induce said settlement, Claimant (and Claimant's attorney if applicable) agree(s) by on behalf of myself(ourselves) and my(our) heirs, executors, administrators, and assigns, that I (we) will hold harmless and indemnify each and every released party including without limitation (INSERT RELEASED PARTY(IES)' NAME), their insurer, (INSERT INSURANCE COMPANY NAME), all of their subsidiaries, affiliates, parent companies, divisions, contractors, employees, servants, agents, officers, directors and legal representatives, and hold free and harmless from and against any and all losses, claims, demands, cause or causes of action or judgments of every kind and character, which may or could be brought for attorneys' fees, contribution or indemnity, any and all statutory contractual or common law subrogation claims or liens, including, but not limited to, all Hospital liens, workers' compensation subrogation liens, Medicare or Medicaid liens, Social Security disability liens, health insurance liens, Federal, State or local governmental liens. I am of sound mind and.body and fully capable of reading and understanding this agreement. I understand the consequences of my failure to abide by the Extension Act. Done at YEAR. County, STATE this day of CLAIMANT'S NAME STATE OF STATE COUNTY OF Before me, the undersigned notary public in and for said state, on this day personally appeared CLAIMANT'S NAME, known to me to be the persons whose names are subscribed to the foregoing instrument, who acknowledged to me that each executed the same for the purposes and consideration therein expressed. Given under my hand and seal of office this the day of YEAR. ' NOTARY PUBLIC IN AND FOR THE STATE OF STATE My Commission Expires: Done at County, STATE this day of YEAR. CLAIMANT'S ATTORNEY'S NAME (if applicable) STATE OF STATE § COUNTY OF § Before me, the undersigned notary public in and for said state, on this day personally appeared CLAIMANT'S NAME, known to me to be the persons whose names are subscribed to the foregoing instrument, who acknowledged to me that each executed the same for the purposes and consideration therein expressed. Given under my hand and seal of office this the day of YEAR. ' NOTARY PUBLIC IN AND FOR THE STATE OF STATE My Commission Expires: The Estate of Lois J. Summers, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. CIVIL ACTION - AFFIDAVIT OF JOSEPH J. DIXON, ESQUIRE I, JOSEPH J. DIXON, ESQUIRE, being duly sworn according to law, of adult age, hereby swear and affirm as follows: 1. I am Counsel for the Estate of the late Lois J. Summers in all matters regarding a motor vehicle accident which occurred on January 18, 2010. 2. At the time of the motor vehicle accident on January 18, 2010, the late Lois J. Summers was 82 years old. 3. At the time of her decease on May 12, 2010, the late Lois J. Summers was 83 years old. 4. At the time of her decease, the late Lois J. Summers was never married, never had any children, and had lived alone. 5. At the time of her decease, under her Will, her sole beneficiaries were friends. At the time of her decease, the Estate acknowledges that there were no wrongful death damages, but instead all of the damages received are survival damages under Pennsylvania law. See confirming Email to the Department of Revenue attached hereto and marked Exhibit J. Respectfully submitted, By: Joseph J. Dixon, Esquire Attorney ID 28290 126 State Street Harrisburg, PA 17101 (717) 236-8515 Attorney for the Plaintiff SWORN TO AND SUBSCRIBED BEFORE ME THIS ! A DAY Of 4)9'_ / _, 2011. NOTA PUBLIC e?zll aaMMO LTM OF PEN IA NOTARIAL B EAL Jennifer M. Wilson-Notary Public City of Harrisburg, Dauphin County MY COMMISSION D(PIRS APR. 25, 2013 EXHIBIT J Print Page 1 of 1 From: "dixonlaw" To: <shabaker@state.pa.us> CC: Date: Tue, 5 Apr 2011 13:54:10 -0400 Subject: Estate of Lois J. Summers See attachment Joseph J. Dixon, Esq. 126 State St. Harrisburg, PA 17101 (717) 236-8515 (717) 233-5860 FAX dixonlawCpaonline.com http://www.jdixonlaw.com Ltr Shannon Baker April 5 20110001.pdf (Binary attachment) o<s't?/r cy orxo/r ATTORNEY AT tAW 126 STATE STREET • HAPRISBURG. PA 17 101 PHONE: (717) 2338757 • FAX: (717) 2'33-5860 ENTAIL: dxon!akv, Vaon6ne.crnn wWW.jdixu1 aw.crjm April 5, 2011 Commonwealth of Pennsylvania Department of Revenue, Bureau of Individual "Taxes PO Box 280601 Harrisburg, PA 17128-0601 Att: Shannon E. Baker Trust Valuation Specialist, Inheritance Tax Division VIA: FAX, FIRST-CLASS MAIL & Email (shabaker;2:state.pa.us) Re. Estate of Lois J. Summers Dear Ms. Baker: In follow-up to our telephone conversation yesterday, 1 indicated to you that. I represent the estate of the late Lois J, Summers on cMl actions concerning her death. Lois's motor vehicle accident was January 18, 2010, at which time she was 82 years old. When she passed away on May 12, 2010, she was 83 years old. Ms. Summers was never married and never had any children and lived alone. Under her Will, leer sole beneficiaries are friends. At the time of her decease, Ms. Summers had Social Security payments of S 1,063.00 and a pension from the State of Maryland in the amount of $2,31X1.00. In presenting this case to Erie Insurance Company and Nationwide Insurance Company, the arguments I have made all had to do with the lingering death scenario. In follow-up to our conversation, it is my understanding that you feel the damages are all survival damages. 1 agree with that as well. Would you please send me a short Email or FAX to that effect so that I may include it in the Petition of Filing for Approval with the Court. Very truly yours, /v Joseph J. Dixon JJD/nnlg cc: Attorney Shelly Kunkel EXHIBIT K ATTORNEY AT LAW 126 STATE STREET • HARRISBURG, PA 17101 PHONE: (717) 233-8757 • FAX: (717) 233-5860 EMAIL: dixonlawJpaonline.com www.jdixonlaw.com SETTLEMENT SHEET OF ESTATE OF LOIS SUMMERS vs. JANET M. LOHR UNDERINSURED BENEFITS Date of Accident: January 18, 2010 Gross Check from Nationwide Insurance Company ........................... $ 75,000.00 Less Attorney Fee of Twenty-Five Per Cent ................................... $18,750.00 to Joseph J. Dixon, Esquire Total Amount Due to the Estate of Lois Summers ........................... $ 56,250.00 I, Joan L. Stoufer, agree with the above settlement of the late Lois Summers underinsured insurance claim against Nationwide Insurance Company. I will receive a check in the amount of Fifty- Six Thousand, Two Hundred and Fifty Dollars ($ 56,250.00), in settlement of the underinsured claim against Nationwide Insurance Company. Date: Joan L. Stoufer EXHIBIT L The Estate of Lois J. Summers, IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO. CIVIL ACTION - JOINDER OF SHELLY KUNKEL, ESQUIRE I, SHELLY J. KUNKEL, ESQUIRE, do hereby certify and affirm that I have reviewed the Petition For Approval Of Settlement and I am in agreement with it. I am Counsel for the Estate of the late Lois J. Summers. By: &L' Shelly J. nkel, Esquire SWORN TO AND SUBSCRIBED BEFORE ME THIS DAY Of , 2011. 1 TAR PU ONWE ALTH OF PENNSYLVANIA NOTARIAL SEAL Public DEBBI SUE MIDDAUp H,? Cou City of Harrisburg, My commission Expires October 2 510 13 VERIFICATION I verify that the statements made in this Petition , are true and correct. I understand that false statements herein are made subject to the penalty of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities. Dated: " , 1 L CERTIFICATE OF SERVICE AND NOW, this day of 2011, I, Joseph J. Dixon, Esquire, hereby certify that I have served a true and correct copy of the foregoing Petition To Settle Wrongful Death and Survival Claims Under 42 Pa C.S.A. §2206 this day by depositing the same in the United States Mail, first class, postage prepaid, in the Post Office at Harrisburg, Pennsylvania, addressed to: Chris Rudai Special Claims Representative Nationwide Insurance NESRO Class Claims One Nationwide Gateway, Dept. 5867 Des Moines, IA 50391-5867 Erie Insurance Attention: Lori Renaldi-Waqar, Liability Specialist P.O. Box 2013 Mechanicsburg, PA 17055 The Law Office of Joseph J. Dixon, Esquire By: J SEP J IXON, ESQUIRE ATTORNEY ID #28290 126 STATE STREET HARRISBURG, PA 17101 (717) 233-8757 ATTORNEY FOR PLAINTIFF DO/ t.5 The Estate of Lois J. Summers, IN THE COURT OF COMMON PLEAS :7. C- N C= CUMBERLAND COUNTY, PENNSY-b%NI*_ • M?-?, NO. 11-35q3 eivil- -x'o b CIVIL ACTION - < ca ORDER = ? AND NOW, this day of r , 2011, upon consideration of the Petition tc cd -a rn ? C) -d+ C? :ij Settle Wrongful Death and Survival Claims Under 42 Pa. C.S.A. § 2206, it is hereby ordered and decreed as follows: A gross settlement of wrongful death and survival claims in the amount of Three Hundred and Seventy-Five Thousand Dollars ($375,000.00) is approved. 2. Attorney's fees for representation to Joseph J. Dixon, Esquire, in the amount of Ninety-Three Thousand, Seven Hundred and Fifty Dollars ($93,750.00) is approved. Reimbursement of costs to Joseph J. Dixon, Esquire, in the amount of Two Thousand and Thirty-Five Dollars and Eighty-Four Cents ($2,035.84) is approved. 4. The estate of Lois J. Summers shall net from the two motor vehicle death claims, Two Hundred and Seventy-Nine Thousand, Two Hundred and Fourteen Dollars and Sixteen Cents ($279,214.16). 5. All proceeds from the settlement should be considered survival damages. 6. Any potential interest of Medicare in this claim is protected by the excess medical bills policy in effect from Nationwide Insurance Company. BY THE COURT: Joseph J. tixon, `10L - hand kii erect 4liqla