HomeMy WebLinkAbout12-0667IN RE: PETITION FOR : IN THE COURT OF COMMON PLEAS OF
APPROVAL OF SETTLEMENT : CUMBERLAND COUNTY, PENNSYLVANIA
OF A MINOR'S CLAIM CIVIL ACTION - LAW
REGARDING AMIR MOUSA NO. 12-667 CIVIL TERM
IN RE: PETITION FOR APPROVAL OF SETTLEMENT
OF A MINOR'S CLAIM REGARDING AMIR MOUSA
ORDER OF COURT
AND NOW, this 21St day of February, 2012, upon consideration of the Petition for
Approval of Settlement of a Minor's Claim Regarding Amir Mousa, a hearing is
scheduled for Wednesday, the 4t'' day of April, 2012, at 9:30 a.m., in Courtroom No. 5,
Cumberland County Courthouse, Carlisle, Pennsylvania.
BY THE COURT,
Christylee L. 'Peck, J.
Mona Elmandali
v' Talat Mouse
4800 Charles Road, Unit N
Mechanicsburg, PA 17050
Petitioners
,/Aaron S. Jayman, Esq.
425 North 21St Street
Camp Hill, PA 17011
Attorney for H.S. Health System
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IN RE: PETITION FOR APPROVAL IN THE COURT OF COMMON PLEAS OF
OF SETTLEMENT OF A MINOR'S CUMBERLAND COUNTY, PENNSYLVANIA
CLAIM REGARDING AMIR MOUSA CIVIL ACTION-LAW
NO. 12-667 CIVIL TERM
IN RE: PETITION FOR APPROVAL OF SETTLEMENT OF A
MINOR'S CLAIM REGARDING AMIR MOUSA
ORDER OF COURT
AND NOW, this 4th day of April, 2012, after argument
in this matter on the Petition for Approval of Settlement of a
Minor's Claim Regarding Amir Mousa, the Court hereby grants leave
to counsel for H.S. Health Systems to amend the Petition that they
helped the parents of Amir Mousa to file with this Court, to
include a. recent estimate from Hershey Medical Center as to what
the costs of the circumcision repair procedure would be in 2012.
Counsel for H.S. Health Systems is also ordered to
file an amended proposed full and final release for Ms. Mousa to
sign that removes paragraph No. 8 regarding any confidentiality
clause. This leave to amend the petition shall be completed within
30 days of the date of this order. Once this Court receives an
Cj ev
amended estimate from Hershey Medical Center, this Court wi]!;? tan._,'
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entertain the signing of the petition for the settlement. ? rn -a
By the Court,
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Pe?L
Christyl e L. Peck, J.
? Mona Elmandali
Talat Mouse
4800 Charles Road, Unit N
Mechanicsburg, PA 17050
Petitioners pro Se
Aaron S. Jayman, Esquire
425 North 21st Street
Camp Hill, PA 17011
For H.S. Health System
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,,
PENNSYLVANIA
" P11 AND COUNT
- NSYLVANIA
IN RE: No. 12-667
PETITION FOR APPROVAL OF
SETTLEMENT OF A MINOR'S
CLAIM REGARDING A1VIIR MOUSA
SUPPLEMENTAL PETITION FOR APPROVAL OF SETTLEMENT OF A MINOR'S
CLAIM REGARDING AMIR MOUSA
AND NOW come the Petitioners, Amir Mousa, a minor, by and through his parents and natural
guardians, Mona Elmandali and Talat Mousa, and Petition this Honorable Court for approval of the
settlement of a minor's claim as follows:
1. This is a dispute involving the necessity of a circumcision repair for Minor-
Petitioner, Amir Mousa.
2. The repair is a cosmetic procedure requested by Petitioners.
3. The cost associated with the repair is $3,405.00. The estimates from Hershey
Medical Center for the repair are attached hereto as Exhibit "A."
4. The parties have agreed to amicably resolve this dispute without the filing of a
lawsuit.
5. Minor-Petitioner, Amir Mousa's, date of birth is August 5, 2008.
6. Mona Elmandali and Talat Mousa, are the parents and natural guardians of Amir
Mousa, and reside at 4800 Charles Road, Unit N, Mechanicsburg, PA 17050
7. The Petitioners and H.S. Health System have agreed to a resolution of the minor
Petitioner's claim for four thousand dollars ($4,000.00).
8. All parties believe said offer of settlement to be fair and reasonable under the
circumstances since prosecution of this matter would require the retention of counsel, an expert and
potentially protracted litigation.
9. Consequently, the Petitioners request that this Honorable Court approve settlement
regarding the disputed medical negligence claim of the minor Petitioner against H.S. Health System.
10. All settlement proceeds will be deposited into an interest bearing account insured
by the Federal government and shall be used for the sole purpose to pay for the costs associated
with the circumcision repair.
11. The parties request this Court permit Petitioners to execute the attached release
attached hereto at Exhibit "B."
WHEREFORE, Petitioners request that the Court enter the attached Order.
Respectfully submitted,
Date:
Mona Elmandali, parent and natural
guardian of Amir Mousa
Date: / ?IAL J ?-k
Talat Mousa, p an - ral guardian
of Amir Mousa
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
ORPHAN'S COURT
IN RE:
PETITION FOR APPROVAL OF
SETTLEMENT OF A MINOR'S
CLAIM REGARDING AMtR MOUSA
No. 12-667
VERIFICATION
We verify that the statements made in the foregoing PETITION FOR APPROVAL OF
SETTLEMENT OF A MINOR'S CLAIM REGARDING AMIR MOUSA are true and
correct to the best of our knowledge, information and belief and request distribution in
accordance with the instant Petition. We understand that false statements herein are made
subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to
authorities.
Date:
Date: :0/9 &
Mona Elmandah, parent and natural
guardian of Amir Mousa
Talat Mousa, par atural guardian
of Amir Mousa
EXHIBIT "A"
05/04/2012 FRI 12:39 FAX 7178350215 HOPS-MAIN
H-J.7
outpa ril
S-9-ry
Center
Hershey Outpatient Surgery Center
15 Hope Drive
Hershey, PA 17033
Ph. 717-520-8200 Fax. 717-835-0215
May 4, 2012
To Whom It May Concern,
Hershey Outpatient Surgery Center has been requested to provide a self
pay quote for Amir Mousa.
The facility charge for CPT codes 54163 and 54162 is $1000.00 as these
codes are generally bundled. It is our policy to collect payment for self pay
procedures prior to the surgery.
We are happy to help with any questions or concerns.
Th You
0?p
Cathy Kli ger, billing specialist
0002/002
PENNSTATE Milton S. Hershey Medical Center
® Milton S. Hershey Medical Center Patient Financial Services Dept
P.O. Box 853, Mail Code A410
College of Medicine Hershey, PA 17033-0853
Phone: (717) 531-3805
Fax: (717) 531-7269
PriceEstimate anhmc.osu.edu
PLEASE COMPLETE 1 FORM FOR EACH CPT CODE UNLESS ALL CPT CODES ARE BEING DONE TOGETHER
PRICE ESTIMATE REQUEST (to be completed by requester)
Date of Request: 5/1/2012
Date of Service: WA
Requested By: Aaron Jayman Attny at Law
Estimate provided for. Patient Physician x Attorney
Insurance company Other MA
Patient Name: Amir Mousa
Physician: WA
Procedure Name: Revision of Circumcision
Unilateral Procedure
Will procedure include drug therapy?
Will procedure include Implantables?
Outpatient YES
Estimated OR Time
Bilateral Procedure
If yes, Drug Name:
Estimated Dosage/Units:
It yes, type of implantable:
Inpatient
Estimated LOS:
Is the Patient an Employee?
Extension: 7177314800
MRN:
Diagnosis:
Procedure Code
and Modifier. 54162!54163
HOSC
Special Instructions:
PRICE ESTIMATE COMPLETION (to be completed by Price Estimate Group)
Date of Estimate: 5/1/2012
Estimate Prepared By:
Patient Estimate
Physician / Surgeon $1,429.00
Anesthesiologist $ 976.00
Hospital HOSC
TOTAL ESTIMATE $2,405.00
Comments:
Received Via: VOICE MAIL
Estimate Emailed To:
Please note this is an estimate and may not reflect the actual charges at the time services are rendered.
The estimate is subject to change based on the amountt of time elapsed from the dale of the estimate to the actual procedure and/or complications
not known at the time of the estimate.
EXHIBIT 6B"
1105163
FULL AND FINAL RELEASE
1. FOR AND IN CONSIDERATION of the sum of FOUR THOUSAND DOLLARS
($4,000.00) payable within thirty (30) days of the receipt of an executed original of this Full and
Final Release, for the sole purpose of Amir Mousa's revision of circumcision procedure, the
undersigned hereby fully and forever releases, acquits, and discharges: H.S. Health System; Holy
Spirit Health System; Holy Spirit Hospital, their affiliates, parent corporations, their trustees,
members, successors, affiliates, directors, officers, employees, physicians, nurses, therapists,
technicians, agents and servant and ANY AND ALL OTHER PERSONS, CORPORATIONS
AND/OR OTHER ENTITIES that are or might be claimed to be liable to the undersigned, and
Amir Mousa, whether or not such persons, corporations and/or other entities are named herein,
including the heirs, executors, administrators, successors, assigns, attorneys, insurers, servants
and employees of each of them (hereafter referred to collectively as "Releasees"), from any and
all actions, causes of action, claims or demands of whatsoever kind or nature and for any known
or unknown injuries, losses and damages allegedly sustained by the undersigned, and Amir
Mousa, and related in any way to any incident involving and/or medical or professional health
care services rendered to Amir Mousa by Releasees on the premises of the Holy Spirit Hospital
and/or Holy Spirit Health System at any time up to and including the date of execution of this
Full and Final Release.
2. The acceptance of said sum is in full accord and satisfaction of a disputed claim and the
payment of said sum is not an admission of any liability.
3. This release and settlement is intended to cover and does cover not only all now known
injuries, losses or damages, but also any future injuries, losses or damages not now known or
anticipated, but which may later develop or be discovered, including all the effects and
consequences thereof.
4. The amount stated in this Full and Final Release is the consideration of this release, and
the undersigned voluntarily accepts said sum for the purpose of making a full and final
compromise, adjustment and settlement of all claims that the undersigned and/or Amir Mousa
and any of their beneficiaries might now or in the future have for any injuries, losses or damages.
5. This is the complete release agreement, and there are no written or oral understandings or
agreements, directly or indirectly connected with this release and settlement that are not
incorporated herein.
6. The undersigned hereby agree on their own behalf and on behalf of Amir Mousa, his
heirs, beneficiaries, successors and/or assigns, to indemnify and save forever harmless the
Releasees from and against any and all claims, demands or actions, known or unknown, made
against the Releasees by any person or entity on account of, or in any manner related to the
injuries, losses and/or damages covered by this Full and Final Release.
1105163
7. In the event court approval is required for settlement, compromise or resolution of this
claim, this settlement is conditioned upon the undersigned promptly undertaking all necessary
action to obtain any required court approval for the settlement, compromise or resolution of this
claim. If this settlement is ever determined by any court to be without effect because some
necessary court approval was not obtained, or if any Releasee is subjected to further legal action
or claim that could not have been instituted or presented had proper court approval been
obtained, the undersigned agrees to indemnify Releasees for any future loss, cost, or expense,
including but not limited to, reasonable attorney's fees for defending, litigating and settling any
such claim or action, and for any judgment resulting from any such claim or action.
8. The undersigned and her counsel represent that there are no asserted or potential claims
or liens against the undersigned or their assets, or the assets of Amir Mousa by any third-party
payor, including but not limited to Medicare, Medicaid, the Pennsylvania Department of Public
Welfare, Pennsylvania Blue Shield, Blue Cross of Western Pennsylvania and Champus. If such
a claim or lien is ever asserted, the undersigned agrees to satisfy such claim or lien from the
funds received from this settlement and to indemnify and hold harmless Releasees from and
against any and all losses, claims, liens, charges, fees, costs (including reasonable attorney's
fees), interest or other sums incurred as a result of any third-party payor asserting, imposing or
enforcing a claim or lien related in any way to the injuries or damages for which Releasees are
making payment to the undersigned under the terms of this Release.
9. This agreement shall be binding upon and inure to the benefit of the undersigned, Amir
Mousa and Releasees, as well as the successors, assigns, heirs, executors, administrators, and
legal representatives of all of them.
10. THE UNDERSIGNED HEREBY DECLARES that they have capacity and are duly
authorized to enter into this Full and Final Release, that they have read all of the terms of this
Full and Final Release, have discussed them or had the opportunity to discuss them with their
legal counsel, fully understand them and accepts them for the express purposes of settling the
above-described claim and for precluding forever any further or additional legal action arising
out of the aforesaid claims and/or circumstances.
IN WITNESS WHEREOF, we have set our hand and seal this day of
.20
1105163
SWORN to and subscribed before me this
day of 52012 Mona Elmandali, Parent and Natural
Guardian of Amir Mousa, a Minor
NOTARY PUBLIC
Social Security Number
Address:
Talat Mousa, Parent and Natural
Guardian of Amir Mousa, a Minor
Social Security Number
Address:
CERTIFICATE OF SERVICE
AND NOW, Aaron S. Jayman, Esquire, hereby certifies that I did serve a true and correct
copy of the foregoing upon all counsel of record by depositing, or causing to be deposited, same
in the U.S. mail, postage prepaid, at Camp Hill, Pennsylvania, addressed as follows:
By First-Class Mail:
Mona Elmandali
4800 Charles Road, Unit N
Mechanicsburg, PA 17050
IN RE: PETITION FOR : IN THE COURT OF COMMON PLEAS OF
APPROVAL OF SETTLEMENT : CUMBERLAND COUNTY, PENNSYLVANIA
OF A MINOR'S CLAIM CIVIL ACTION -LAW
REGARDING AMIR MOUSA NO. 12-667 CIVIL TERM
IN RE: PETITION FOR APPROVAL OF
SETTLEMENT OF A MINOR'S CLAIM REGARDING
AMIR MOUSA
ORDER OF COURT
AND NOW, this 5`" day of June, 2012, after a hearing on this matter, and upon
consideration of the Petition for Approval of Settlement of a Minor's Claim and
Supplemental Petition for Approval of a Settlement of a Minor's Claim regarding Amir
Mousa, it is hereby ordered that the Petition for Approval of the Settlement of a Minor's
Claim regarding Amir Mousa is granted. Petitioners are authorized to enter into a
settlement on behalf of Amir Mousa in the gross amount of four thousand dollars
($4,000.00). All monies from the settlement herein shall be used solely for the purpose
of any medical repair procedures regarding the minor Amir Mousa. In the event that any
monies from the settlement are left remaining after the payment of all expenses relating
to the medical repair procedures, such leftover monies shall be used exclusively to benefit
the minor. All settlement proceeds provided for herein shall be deposited into an interest-
bearing account in a federally insured bank or savings institution having an office in
Cumberland County. Petitioners and Attorney Aaron S. Jayman, acting as counsel for
H.S. Health System, shall jointly file proof of the deposit of the minor's funds within
thirty (30) days of the date of this Order.
PETITIONERS are further authorized to sign the Full and Final Release attached
as Exhibit B to the Supplemental Petition for Approval of a Minor's Claim regarding
Amir Mousa and to mark the matter settled, discontinued and ended as to the Respondent.
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BY THE COURT, r_";e
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Christylee L. Peck, J.
i/ Mona Elmandali and Talat Mousa
4800 Charles Road, Unit N
Mechanicsburg, PA 17050
Petitioners, pro Se
V Aaron S. Jayman, Esq.
Dickie, McCamey & Chilcote, P.C.
425 N. 21s' Street
Camp Hill, PA 17011
Attorney for H.S. Health System
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94-
1303117
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIAc
IN RE: PETITION FOR APPROVAL No. 12-667 Z? r--
OF SETTLEMENT OF A MINOR'S CLAIM u'D
REGARDING AMIR MOUSA
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PRAECIPE TO DISCONTINUE -i c.n
-< rv
TO THE PROTHONOTARY:
Please discontinue the above matter with prejudice pursuant to Pa.R.C.P. 229.
Respectfully submitted,
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Date: I r
Mona Elman ali, parent and natural
guardian of Amir Mousa, Pro Se
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Date: ON- COO\
Talat Mousa, pare ral guardia
of Amir Mousa, Pro §=---?
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CERTIFICATE OF SERVICE
AND NOW, July 10, 2012, Aaron S. Jayman, Esquire, hereby certifies that I did serv? a
true and correct copy of the foregoing upon all counsel of record by depositing, or causing to
deposited, same in the U.S. mail, postage prepaid, at Camp Hill, Pennsylvania, addressed
follows:
By First-Class Mail:
Mona Elmandali
4800 Charles Road, Unit N
Mechanicsburg, PA 17050
Aaron ?r J)ly)na6f, Esquire