HomeMy WebLinkAbout12-5195ORIGINAL
BENNETT, BRICKLIN & SALTZBURG LLC
BY: Curtis C. Johnston
I.D. No. 64059
222 EAST ORANGE STREET
LANCASTER, PA 17602
(717) 393-4400
ATTORNEY FOR PETITION]
State Farm Mutual Automobile
Insurance Company
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY
One State Farm Drive
Concordville, PA 19331-0041
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
Petitioner CIVIL ACTION -LAW
~ t -, r.~
~ rte= _...-
~. 5l 15 .~
NO: ?off -~' ;~
n~ :.~ ~~.
DAVID E. WISER : ~ 4.;
333 Greenspring Rd., : c~ ~" ~.°~
Newville, PA 17241 rte, ~ ~
Respondent ~ c-7
~~
-'- R~
~. ~ ..
--+ ~
JOINT PETITION FOR APPROVAL OF LUMP-SUM SETTLEMENT O~'
DAVID WISER'S NO-FAULT BENEFITS
PURSUANT TO 40 P.S. SECTION 1009.106~b1
AND NOW comes Petitioner, State Farm Mutual Automobile Insurance Company
Respondent, David E. Wiser, and hereby jointly petition this Court for approval of a lump
settlement of No-Fault Benefits pursuant to 40 Pa.C.S.A. § 1009.106(b), and in support thereof
as follows:
I. THE PARTIES
Petitioner, State Farm Mutual Automobile Insurance (hereinafter "State Farm") i~
a mutual insurance company incorporated under the laws of the State of Illinois, with its
place of business in Bloomington, Illinois and a business office located in the Commonwealth
Pennsylvania at One State Farm Drive, Concordville, Pennsylvania, among others.
~_-~
~_~ry
t
s-n
~i
. ;,
r. ---
~ C"ii
--C
a~ 03.? Spd a the
C ~ ~7l ~3
~#a7~SA~2
2. Respondent, David E. Wiser, Pro Se, is an adult individual residing in
Commonwealth of Pennsylvania at 333 Greenspring Rd., Newville, PA 17241.
II. BACKGROUND
3. This Petition is for approval of slump-sum settlement of No-Fault Benefits under
former Pennsylvania No-Fault Motor Vehicle Insurance Act of July 19,1974, No. 176, P.L. 489,
P.S. § 1009.101, et sea. ("No-Fault Act").'
4. The accident giving rise to these proceedings occurred on March 4, 1982.
5. In the accident, a Ford Bronco operated by then twenty-seven year old David Wi
overturned and collapsed, resulting in serious personal injuries including a fractured thoracic spi
which rendered him a paraplegic without the use of his legs.
6. Immediately following the accident, Mr. Wiser underwent a spinal fusion and
medical procedures and care.
7. Since the accident, State Farm has provided No-Fault Benefits to David Wi
pursuant to an automobile insurance policy issued under the No-Fault Act. (Eachibit "A" - Poli
Endorsement) under Claim #38-5485-758. To date, State Farm has paid the costs of all accide~
related outpatient and inpatient medical care, medical equipment and supplies, home remodeling
1982 to accommodate his changed needs, and subsequent home modifications in 1996, 2006, a
2011 when Mr. Wiser moved, and other items. Over the last thirty (30) years, State Farm has pa
' The No-Fault Act became effective in Pennsylvania in 1974, and was repealed by the
Act of Feb. 12, 1984, P.L. 26, No. 11, §8(a), effective Oct. 1, 1984 when it was replaced by the
Pennsylvania Motor Vehicle Financial Responsibility Law [75 Pa.C.S. §1701, et se .. The
repeal of the No-Fault Act did not affect Mr. Wiser's continuing entitlement to No -Fault
benefits.
2
approximately $607,014 or more in No-Fault Benefits, a significant portion of which was paid
after the accident.
8. Following his 1982 spine surgery and initial recovery from the accident, Mr.
has had a relatively stable course despite occasional medical issues and hospitalizations, additi
spinal surgery in 2002, and a progressive degenerative condition in his shoulders.
9. Now fifty-eight (58) yeazs old, Mr. Wiser is married and currently resides at 3$3
Greenspring Road, Newville, Cumberland County, Pennsylvania 17241. Although Mr. Wiser
not have the use of his legs, he has the use of his arms, and is mobile by virtue of a wheelchair.
works part-time at a home improvement store, is able to drive, and engages in hobbies
hunting. Mr. Wiser does not require home health caze and is relatively independent in his
of daily living.
10. Recent medical reports aze attached hereto: Report dated May 8, 2012 by
J. Green, M.D. of Appalachian Orthopedic Center, LTD, who assessed Mr. Wiser's
problems-Exhibits "B" ;Report dated May 17, 2012 by Dr. James L. Hardesty of Cazlisle
Medical Center Wound Care Center concerning an ulcer on David Wiser's left heel -Exhibit
III. RELIEF SOUGHT
11. Mr. Wiser has approached State Farm with an interest in entering into a
settlement of his No-Fault Benefits.
12. After some discussion, State Farm has agreed to pay Mr. Wiser, who has agreed
accept, a lump sum payment of Six Hundred Thousand Dollars ($600,000) in exchange for a full a
final release of State Farm's obligation to pay any further No-Fault Benefits arising from 1
March 4, 1982 accident, contingent on this Court's approval as required by Section 1009.106(b)
the No-Fault Act. (Exhibit "D").
3
13. Mr. Wiser understands and consents to the lump-sum settlement and full and
release ofhis No-Fault Benefits, and joins State Farm in seeking this Court's approval .See
"E" -Consent of Insured.
14. Mr. Wiser affirms that he believes the settlement and release aze in his best
and those of any beneficiaries. Id.
15. Mr. Wiser understands and agrees that the settlement proceeds aze intended to be
to cover any future medical expenses and/or any other expenses of any nature he may incur
are causally related to the injuries sustained in the subject accident.
16. Mr. Wiser further understands and agrees that any such future medical expenses
other expenses may not be compensable under any applicable Medicare or Medicaid
and/or, if paid by Medicare or Medicaid, maybe subject to a claim by Medicare or Medicaid
him for reimbursement. Mr. Wiser further understands and agrees that State Farm shall not
responsible or liable to reimburse Medicaze or Medicaid for any such sums, and that he
indemnify State Farm for any such sums which State Fazm is compelled to pay in accordance
the terms of the General Release attached hereto as Ezhibit "G" which he shall execute
connection with this settlement.
17. State Farm will have no obligation to Mr. Wiser or his estate for No-Fault
arising from the accident of Mazch 4, 1982 incurred after the date of this Court's Order
this settlement.
18. The settlement is full and final, and shall not be subject to modification in the
under any circumstances whatsoever.
4
19. State Farm is paying for all costs and fees associated with this proceeding,
the fees of the attorney listed below, and hereby verifies that same are not being deducted from
settlement amount.
20. Mr. Wiser has been advised of and understands his right to be represented in
proceedings by an attorney of his own choosing at State Farm's expense, but has chosen to
without an attorney.
21. The settlement was not procured by fraud, and its terms aze not unconscionable.
22. As Mr. Wiser is an adult of sound mind and capable of handling his own affairs,
parties to this Petition do not make any request concerning the disposition of the proceeds of
settlement, same being at Mr. Wiser's discretion. Mr. Wiser understands that management of
settlement funds shall be his responsibility.
23. No promises, considerations or inducements, other than the consideration in
amount stated herein, have been made by State Farm to Mr. Wiser in connection with this
and release.
24. Upon receipt of an Order from this Court in the proposed form attached hereto
Exhibit "F", Mr. Wiser agrees that he shall execute a General Release attached hereto as
«G»
25. Neither State Farm or Mr. Wiser have been placed on notice of any Medicaze or
governmental liens.
26. For all of the foregoing reasons, the parties hereto respectfully request Court
and specific findings pursuant to 40 Pa.C.S.A §1009.106(b), in order for the proposed
settlement to be effective to release State Farm's obligation to pay any further No-Fault
5
~S
~r~' HfI ~ ~ ~ IC~C~ i~ P~~r ~ ~ dam' r+e
S~ffi~iC IE~IdCt
BE~~1~'E7T, BR,K"Ki~ & ~ALTZBiJRG 1 "T .C"
BY: ~ 1~{~IZ
Gratis C. Jam fay P - .
David E. Wiser, Pro ~Se, Respoident
08/09/12 06_47FA.Y 610615719
I, SHARON A. HOFFMAN, hereby verify that I am a Chian Representative for State
Mutual Automobile Insurance Compairy, and that the facts sat forth in the foregoing Joint Petiti
forApproval of]Lump-Sum Settlement ofl7avid V~iset's No-Fault Becs~efits Pursuant to 40 Pa.C. S,
§ 1009.106(b) arc true and correct to the best ofmy lmowledge, information and belief. I understa
that false statements therein made aze subject to the penalties of 18 Pa.C.S, § 4904 relating
unsworn falsification to authorities.
Date: ~ ~ ~~` ~
002
\WbtdacslCPSt~arclCPWinWistory\1208U8 0001\8388.1 t
J' ~ _ T __.~._.... .~_
This eadocaetaeat npbces .~ tem>ftaw eadacseatent 6aZ41N dated July 19. 195 which was
paarlotaiy. The chanpes yon rapxstsd bare beam mtda and acs mdkated by the oowra=s desiptatlea I,
• tits Aekaot~sdeatent of Corengs $detxtiona faem.
.• ~.;.. •
. 68?A.1N PERSONAL 1Nh7RY?ROTEG7iON ENDORSE14dENT
(CoraaRe P - tessasylraaia)
s
• ". +
. Noddn~ herein contained shad be held to slur, racy.. weirs a extend nay of me tarry, caadtied
' . ~ ap~sements or lhnibdons of the uadermentlowd pdiry other"dtan as stated herein 6eMw.
. . •• Eftacdre oa the dame shown oa the Acbto~rladsemsctt of Corecape Selectiaos tam.
Issued by the STATE FARM MUTUAL AVT(R/~.E JIVSURAIVCE CQMPANY, of Sloomiastanj
i::.'' ' lltiaais, or the. STATE. FARM FIItB ANIti CA~lAL1Y C~B'AP1Y, of Bloorninftoa, tgiaois, as indkate~
• ` . ~ ~ by the company name oa die policcy of rvhidt thb sadorscrnent b a part.
i ~ ~ This eadoesanent is subject to ai! the pmvhians of the policy except as modified herein:
• ~ COVERAGE P-PERSONAL INJURY. (b)waeicloee,
• • ' PROTEL"fION COVERAGE ~ (c) rglaoeseat services loos,
'• '.' ~ .E~and
• •' In accardsna with the Peadrylranis NaFsdt (e) meriror':lar .
' ' _ Motor Vehtde Iosuraace Act, the company will pay ~ ; ~ ~ ~
any or aI1 persoetat injury protection 6eaefits for: P~+ due to an',
accident resultiuJ from the maiateaaace a use of s.
• (a) medial ~ motor rebide ai a vehicle.
EXCLUSIONS
• this corenle DOES NOT APPLY to 6odIIy Iojtsy to:
Second auto if not bleared ender ' (aj the named iasvrod or nay se>itire reiuItict= from the raaiataaaaca or
this poiky. use of the cttmed htsnsed's motor rehicb which tr NOT as iosursid '''
• ~ motor vehicle;
• Rsiovas wba don't bare tlklr (b) any rrbore sesWtiag front maiatenanca or use of hi: motor rddds
own autos bleated. which does not sleet raquiramenta of the Peanryfiania No-Faa1t ~[otor
• Vehicle Insunaa Act; •
Rebores who here their own (c) nay ~rebtire entitled to Pennrylraab personal injury proteciion
_ auto iusatarnx. coverage tt a self3nsuted or as a named htwred in another insurma
_ P~cY;
. Persorii coaxed by their own (d) any parson, accept the mined Insured or nay tebdr~e, if entitled to
ant~i~atuana. Pennsylvania personal injury protection covenge as aself-insured or as
a named bastu+ed or cebtire in another insurance polity;
" _ _ - __ !i
' l• ' .• , , w ~ `• III
~.
i • ~ ~
i .
- • ~ .
.
. ~ ~ tnsoo got caeryl~ Ymia i~ (e) anY person oocrpylq , or is a pedestrian struck by, a a+wtar
• 1 e~ceae of tltoee rued. osvaed by sudt~persca, -to the sxteat the dmid provided by dice
'
.
. .::,, ~ ~ ~aroeed the miniaittati lEesib tequised by the tenroyhaMa No- aWt
:•~:' Motor VehiCle;e Act. ~ "
~f is esaploysr'i vehicle. ' {~ the sawed lm~ed or say rebtlre white ooarsfrl-ly hit eaipi 'e-. .
aaotor eeldcle, other dsatt the iaereei tuoeor veYtte, for whiclat ty .
. _ fs Rrtakhed a~der the Psaatylvsds NoFs~t Motor Viiside
~ • •
•'
, ~ Act; but dra arclusioa doee•not apply to nay portion of the lisni of
liabiliry• is .acoese of the minimum dmia of security required by
. i.°a'~''.',.' ~.t,
si
- ' '• `• i ~~~ ~t•~• ~ ~Y lx~'~~E from the conduct of fhe busiae>s of
- •
.. ..
~ servicing, or ol6enrbe msiutaioin= motoi vehicles unless the con t: . .
• :•'• - ~ occurs off the buslaasr prsmlres;
- -j•~g ~ ~ fh) ~Y Few 1o~iaf a ualoadifig ~ mY htoter w)tiele excxpt
°
•
... ~ oocapYlag a motor etiiele;
•
" . ' . • ~. . iMotoe+cYda•' : " ' ~ (i) any person while obanpl-iaf i motorryde; _ - I
.
•_ . Csr titievae. (~ stiy person othei than .the anred conned a any retstlve,
'
'
"'
m
ainta~~oc
~q s motor wi
W
e without reaeooa6~le belief that
~
j
~
~
~/~
;;,~ .
.. ~ .+ ~ endued b d0 so; Aa tllatl ala7lhOr~a lose benaBts be pays
-
to blest. or his is~ivor(ar
- ~
'_~ Padestriam ~ other states. (1~) my ~ other .tt,aa the mined iawred « nay ~elitive
if .
...
,
• " , - accident occurs onside We Commea~waldi of P~eAnsylr~i:; ;
.~
"' Parked ~ iehkles, etc. (1) arty ptrsoa wbbe aaintsiairig or using a motor vddde wlrr~ !oq
. . , for use as s rertdeaoe or premises; ~ ;
" .. ~ War, rbt, e!~ ~ {m) any.. person ~ .dne to ~ wu~ whether - ~ not ; dedered, dull ~ , ~ 1 ~ .
. insurrecttap; revolutiiaa ~ nbelHaa or any aoeompartyi<ig act's -
~ i `
. .. ~ conaitioiis;
. " ..
• • ..~ ..:.. - Nndear (n) aiy persoa.Gaused ~ nudeu radiorctivity •or ex~OSlaa; and " ~ - -
latentiOrre! htjury. {O) any person who lateatio~y injures himaetf or another; AOi ;
.. ..
• sgrvivor's loss benef:ta be payabk to such penoa or his sarriMOi(a). .:
!
.. _ ° DEFINITIONS • . ~ ~ •' .
i
€
.. ~ ~
• . Wherever "he ; "ha", "bun" at "himself" appears ~7' while Oaupylaj, oi~as a pedestrian struck .
• • . in this sndorsemeat you inay substitute "she", by, nay motor vehicle;
•• "her" or "herself".
(b) any other person who sustains lirjory while ;
• - M " µ .. occupying; or as a pedestrian struclt by; the
toddy injury or injury means accident:i bochlY inanred motorv+eltiele; ~
-
• harm and resulting lllne3s, disease or death;
'
~ • - - "farxsal expema" rtyeans reasonable expenses
.
~ "dip'bk person" means ~~th+ related to funeral, buriai,crematlon or other -
.
• • disposition of the remains of the deceased eEip'bie
. (a) the Honed insmnd 'or any relative who sustains person; '
s -
• - i
"iaseret aaotar vehieJe" mMUlls a motor rel~lde
~ ~ ouch sesvias smtat bt allppiitd or pf^OMldtd~
•
~ '• ~ iamlranae
(a) bo whkh the bdry ~y Habihty ~ Pa40° a0eaedlted a •oetpilbd by an
'
• .
~
~_~, ~ Mileh ienkaa :~ ~6ieh atq be a!
• : i :'s'' /
,
(b) fOr . tiie nahned luiltedl tnamtt~la 1K~ a psirate MINI; aad
atiatrity R" req{dred iutdtr the ~ (Cj acid YOgtla~al atiailllta~ton•
• ~ NaFatdt YOtor Vehlcie Irmursace ACt; ~ . ~ tl~tae see aerslat nteearary to rrtdlloi
aald ~D 1fiML'a tilt , pt,}~ai0~ical;, .
- '7oee of ialooaoe" means jrola•io~me aetiial~r loot and *oaadonal. fuaetiad~ of asl
' .~ by an pessop, or that would hs+ne beMl last • ~ thaae iadilde, but are not ffinixd ta,
• hat it not been for ~a income eoatis~p}on plaa,
...
~'
! a
~
~; -
'
~ (:) !~~'i~4e. ;acorns he eartr~
~bl•~tltntt psn
dares
! w arc and eta ,
.o;d~
;:.
.
- „
~k ~ ~~ and ~.
(b) .income he would have earned is available - o~ ~em~'. .
• substitute work •lie was capable 'of Bola= but (4) speech pathdo~y sad audidojy,
~. .. unreasonably failed to uadartaks, o: - ~ . ('~ oPtaoit<ic servicos, .
.~ . •.. {c) any sditraplaymeat income rtasoaably (ti? nn:sias care under the supervision of
_ y em
pioyini an avaDsbia altbtituoe;
obtainable b
i ~!~ ~ ~ •
' i:~ .,.:s ~, ~
' = ''
~ e
+
J.""r"~`~ i.'~Eini It~O~ ~li~•~'a
fa neawty • proms
aad
ioclirre~ '. i1' ~ r+= +
tehaan
; ~ --
"`,;'~ ,
,
. ~
q[a
if
d „,
.
essi~loae;
• ~ ~ •
.
r
a
on. -
sceanmso ,
..
, .
' ' :
' (a) protaaionai medical tnatmeat ><sd exre; this - ' ~) °°0~..~ tools and-
•' • iadudes, but is not IGrdtad to, (I~ l~wperta8eiiot +ldleee ' to
l .s
di
d
l
~
l
blll
• . (1) medial.aad Beata! serrloes; ~ ~ ~ mt
p
t
vocat
aa
se
a
tatian .
.. (2) : eye~ses, bearing aids and, prastlletic ~ ',ail aarvkes aauet be provided by a fudH
•
' ~~ ~ ~ Department of..Health, the
apps~csed by tiie
_
. {3)~ambtrlaacx; egairorkat tavemraeatal a~lacy .n6d~ fai
. ~ (4) hatpital sad lirofssaionai nuisang serrkes ~ .. ar ~e ~~~ ~ a .
~
for diadpaia, cue and recovery.; .however
it depertraegt ~~ a~sacy of.the state m which. thane
-
. ~~ .
. ,
setrioes ~ p~rlded;
does n~ irldude is sxcass of theca for
~
_
~~. ` • . • areana asry rel~de of a kid-.
a semi-pnirate rabm, unless mare iateaaiv~l care ~
d to be reptatered under the Penrssylvaaa
-
~ ~
is medically required; and
a~da Code; .
. (~ afl teaaoasble expenses for say remedial
• reli~OUS .treatment sad care provided by a „ a>ealu ~ persaa or arpnizailoa
• r nli 'oar or Hansed isuthod of
d ~ .. io ~ dedattttans;
heallnt; - !"oc~rylq"• raeaaa is or upaa, entering ~ iato ar
(b) emerperscy health servioes;~ these are aerrIces ~~~ ~;
badly iojnry immediately ~~ = the spouse and say peeon related
necessary to treat
- - • .
following the tcddent; these include, but are not to the• named ;mated by blood, marrIa;e ar,
• limited to - ~optioa, a minor is the custody of the
(1) conanunicatlarss and .. ntrned ~ sFo~ or such related persoq
resident In~ the same household as the named
~(2) trarlsporta8on and treatment by medical ~ whether or not temporarily residinj
and paramedical personnel; elsewhere;
.~ f_
~.
.",
:~ .
r
i.
r
.~-
i
.o-
1 • ~ ~ '~ ~i'•:
. K
• a, ..
. a ~ j , r
' ~ ••r aae*kaa . l0ai'~ mesrte ax~aM/i ~ Ot jay jn ~
~ aQY
.`.' ~.
dins= ~ alyi4 peaorh uaoaaary atMcea aepis~B Wane that the
'. ':;
' ; •~ :~ ~ : ~tlIN. b obhYinj ordisary sssd aecesiary person would Lore rformed
aat~loae wpiady tltam that. (had'lk not been fatally lrtjurrd), wit~enit (~ he ao
~,•~ ,;. Y' pay or peoAt
f
been
h
~
,
. M wovid bare perfoaaed, wlthoat pay or berrte8t, .
• t
eir.
-
~t of histaelf asd hla fondly;
"
~a~ ~d .
man
avoid twos ofof the
• ~' a~ p~"+ deadt from
. ~ (a) a sponge, or _ ~7
~ :
~ _(l-) any of the idtowbag depeadeaat upon ire "!ie~ek laait" nt4ass
: y
::•
-.
.
. daaemed foi tupport at the ~t~te of death of the (a) bait •'of ~eome of an elig~fe perso ss .
~
~ ~ ~~y ~!~ ~, ~ order the Pemrsyiv~nia . Na anlt
r'
• .. • M parent, en'oote .Motor Vehicle Iemuana Aey sari
••' ~ ~_ "saerlvoc'a loss"mans. ~ (b) • reaaaeable . expenses of .A selftrnpi ed
;.-c:'; (a) lom•d.idoome lvhich woWd probably bare P~fableiaB• .
. • • •. _ bean cantrlbated to the ~rrh+or(:~ if the e~r1e (l) ap~~ hdp, ~tLereby enabW~ the
• pegou !ud not•~stabaed.fital Is~oty, and . person to work, or
^ti ti Y %' (b) e~cpa~ • tamaaab~Y . 3ocurred by the :_(1} a mbetitnae,
~~:•: aanlroe(s) ~ftar an person dies as.~ resWt thra~~ of income,
' ' ,,: ~ p4LICY•PLRIQb; TERRITORY.
.. - .. I
. 17~ co~eraie spplies• only to aeddeafs which occnt dudnB the pdky perldd and with the ~tited 3
'
' • •
of Amerces,. ib territories snd.possesaioos or Canada,awhile.~ the.iwred motor a~e.~le•baio
'
j
.
.
between poet thereof; or in Mexico within SO mines of the United St'stea boundary,
• • • ' ~ ~ . ..LIMITS OF LIABILITY ~ '
;:. tR : ~. Reprdkss of ~ the numbei of ptrsasrs - inaired, by the ~ covatapr,os, subhect t
• polides az pLna of aelfdnsunace applicable
elsi'ms
f
^
,
a minimrnt o
51000, nrultlplied by the aver
• ~
made or foaeried motor reLida to which this
~•
per capita lncoma in
Petrruyhynia d?ir#ded
~~ aPP~, ~ company's
liability for .:
.
avenge Pea ppita incos>e is the Urdsed States
penoail injury ptotectiaa baneSts wide respect to shown in the latest available U.S
Department
f
~ b
~
.
o
.
01
Y ~7' to say oar . pesos in anY osq Canmerce figucea; or ~ ,
.. motor rrldde aa~ident is lisrited to the :rrroust of _
each drown in the Schedule by the applicable ~
(b) actual monthly eamiags under S1000
• cm"en8e de:igQation
, Provided that the marcim
if the .
--
.
,
um
the ~n~ bred rduntarily agrees is w~mg wig
' amount payable for work lore shall not exaed j
.
. amount shown is the Schedule,. limited to a ~ company, prior to the accident involving
monthfy maximum of ~Y, that such earnin;s rhai( nreaare Ehe .3
maximum amount of work lose payer to the
• _ (a) the' monthly maximum shown in the Schedule named insrued by the company.
.
•
f
i
1
~ r
t
:. E
L
1
s ,
.
f $ -
'
-
-
• t . . f ~
t•- ~ tY
y
~. • - •> ANY AliiOt)NT !AY
' ~~~ ~ • '~ HY: AaLE HY THS ~OMlANY~U ~g T!~ OF ~8 Ca mil
.,: ~~ ~ .... ar !~ b ee,~pe~w radar ffi. ~
Bir
taf~ •:
. .~ ..~ ~~,y~ \a . ~ ~, io+rr~i t life
~w-,sip,:-r~ ~ ..~ -~: .. ~ rr~ 1itk~7QX ~ '
~ •-. ~' .• •• beeeDti s~ed to a pareari~ ~ Act
I .. - Dove ~ atiali not:e ~7/' ~ t° W° ieael3ts prarlded by tl~
~ . ~... ~ • amonat pryaWe; -
.a~. ~, a~ ~ ! ~~ ~ Jmt.~lr gb~t4ld,by
~ ~•f'e*e,not.•beee peid~ ~.l~!~Ibb+fitae
~' as ! ~ ~ :~.~_~ ~ ~~ . ~ a before We aw~f~t r~ le ~ lee
~' ~..: _ ~Y.'.#~ Win 'It+l.,e~tltlid, .
tae ~[ ~ - ~ ~::~• ,,, ir~o aelwily- ~~'1+~e ~ .
,• :vi;! .. ..,, . .,~~. la~rnt~tricaa~s..i~d~ ~ ~ a .~ a'~+ai'
•, • - : L .S '~N. f ~ of loee Of ilie~iY
. ?N ~. lanta>drratagigt...:. ~. ~'~ ,
. _ i ~~Ctibl! a1DOOHt3. .. ~C~j ~ ~. d~~uCtiLie ahoeiu •itl the ', .
. .;~: .: ~p~`t~ia+dilp•1~Lbtbi.~ ~ . Dut only rrrith
• Waiter parioda, ~~ ~ c~ ~aa ~ 7 ~d iraitrd of eqy +irtilne;
~_ _ ~ s ... ~ ~; ~ the S~eduie dwlaj nap! ~ .~~f -
~'~ ' • _ , . to Bie ~ Oe ~ • ~ ~p+r~ to holy iej~, ~ •
k
1. COrID]'TIONS ~ .
. •' A, Artioa Ate. Cam,. Nc acticutt ~ - ~ -
t ~ y on ibe; shad ~ C' ~iad ~ h+aof of (~,
~'~~;,,. : • , P°noa uaJ~i a~ peraoa >t:: ~°f.+~4X, Pnctiice~y'~~a D~rr4 t+erri~ ~~
all the terms of cover~e, . ..-, ~ttees ~ ~
1' of daim, under w~ it'd
B. Notice. If ~n secideat occurs, written notice ~ridia= ~e natter and exgeat of bodib- r
. adequately ~aStying the eligible person and treatment and rehabBitsKoa may,
• reasonably acme fats roan ~ wed and
puce and drarnost~rns of the ~S ~ one contemplated and other information to aadst ~
given as sooh as practtcaMe scddent -ahatl be . c~rnpany iA detenrdNng the ameuAt-dne yid ~ -
bY or on behalf of aach PaY~.
pia to the carnpany or any of .its
autlrodzed agents, Proof of claim shalt be made upon forma famished
s by the company unless the company ~ to supply
-- . ~. - , -
' ..
i - ~ -~
i
1 ~
s i ~ ~ ~'
I ; - . -~s~
~ ~ •r~ ~ :*
' .~ , .• . ' rrr~t foeae ~ T3 ~ tl~ut aoeirl~ artks of , flra # M ~ a~tr R1i
:~, ~e peeler lieTi .whit t. r~eefrt and p~srrte rae ode. m tie raterK el atarstr
~' ~ ~ ~~ ~b+~ Irk ~~tee~i iT- ilr T~ . ~ ~» sii tsreadae- ,,,t +it~wr
air!! ~ a~! s+11wir tie e+arnpng~ ~;,,~ M pe~ea ~i ~ >re~r+eer ~ ~
~~ tanepite~- ~r8 prtr ~t eaete ; ~ . ~~ ~~ seitit ~s
., 'ldre oaetlwdr,
~ +~!!~ t~ is tie eardt ofaa~ peisoa'a +' ~~~ i~isir r-
Te~~~~~y ~.~ ~) ~, if fire tta~sd
eat to ti~lsie taiical ~r isd of ie dK t N~o-Fselt
seeoei~ A . +et ieitai ~ ~ Tye' ~I~abrG' l~e ~ Ae~, it ~~. y.
~rtraederi to swh time pertet ap~at< Tde rrittart wade w ~+ T ~ ~
. ~~ ~ 11e:
. ~ ~ i~et~te foT f~er st iooetre ~ etsiAeri. dr i' tM ~orr~ sTesd is tttiWi, to tL sz~ 4f.
. • , ' +~M h~ ~ tip ~ ~ ~t0 die of snTr ielwMlwK or
dr a ttitsiR• dietsiir ~~ tsririep psis! to 3a lwot of ~ pe,asa, Tae tie ~ .
'. • •'' . ~ ~. Liar i~'r~sit+~ ~ ~' ~~aieae lNe. mse ambrat ot. aT~ a~oaeic Toirtt .deer. Mid iirek
. ~.,.~ titiie.otti~e~ r ~ ~ ssrit~.t~ iM.+e+wtii~e #
.: TT: tir~~artew iitwiel~raeerp; Trio.twlt btae~ sw ,' lw~ , ~~ r!- !+~ ~ r<
t ae+e~ittTt'artpiir-drr~M ' ~°~''~' M Tt~j-.
f
. .. - ir+~ fir P'a~i~ w+ce ea ~ f`or ie~idr!!1-~ we rt~,ie.~
. = ar • =per fir eerre~e@~iiii iwa a Tierilerlr at~e~et ~e~f tiie .
~sc~oeruteteirTtdit~er-.~Ititie- 3i0 ~ aAer tYr t a~dce ~ ~' M tt~ ~ tie
. ~, .. r ~mr~riRa~iii~le~~eitifailiaaartat>~,., ~*e~~,
~ ~aresiia !root' ~ of ody Tied t~ s oidti a • • i~srp, • ti a~osl. ~ Tnrawr ;sr a nowt M
sappiied arW iM port ~tarrb b;Tti0~tlQar s~ase, .. ~ a the
buts Bor wei prrt see stw..aei~ect b this .: ~, tsde p~ +iti TwTd a tract for fire .
y ~ 1~dTi Titters~t +oa or~rdue pyrsotrrsr to ~ i rata ~ ~ ~ ~
.. ~rtt wrrra~ Tf tie c>soors .~ ~~ Tit splicer firs ~ other paaas ~
,- ~ ac+~a®Irrle tie iiiir sqd, pay tied ort a
hair, tit $~ pg-~esent wwt~Trs eueie trtdda ~!6 . .
~ afMr tie c+o~ony eeraaeiie prao# 3. T~ ~ ~ pmopatT- ~euaiei srwl do .
aad dse aAAtltt ofTor. ~ Tor t4 prcjadce wdl : ~
~ ~ediwi pdrodra~,~tetrtoar aaa acrartamc~e6t~s 'i• saei'pareaa aiaH a srd id~r tn,~
. Tape bson p~noegtd is tie tiylle paaNOa sad die iritnaaaetr aied papers sppropdaie b
]' btTieaas ~ tip f~ fiat dre aapadd se~ew+r tie doh persar rarer die eoar~rsq- . ~ .
por~iaa es!' the exws a fast liars wi bt paid ~ b~ drir prorhica.
tatdea s rsr~soaeiia timt duoa~-. s la+paaerat
ik eegetesi is T+q ss~- +or ~ -• ~ ~pt°J- inr dra :fit a'
e to o~nmrdga plr. ~ ~ ~' ~ wi~- Taos caa+trMd a
meter +etiiele ~o+nitad ~ m a~e+eideat, or s
~ to dre appdaits T~St~ T tee Tale i~~ T~irrdf eu
~ tt~a Aaaagri~r No~F~dt T Ye~Cte sootier p<siaon, for nod`autt 6ene8es pii 6or
~, ii' aaY pi!'~t it at~ds mrei;r tt'gs 1. as Toes eared by tie ecadnct of ti~tt pe:orua, .
ei
,~
._
~~
( i ~ • '
. ; : t ;_ ; . 2~ flra tact of P ~ ~ Ibr lode Io se cue tles~ tfrt rooN~r1- M.~it lira
• _ MMd and ~ +~ ar. ~ ~ ~ ~ M ~i l~~ ~ .
. ~ :. ••, ~ 3. rua tart +of ~ +at
~r tles ogre ~4ae~r d Iasi oooior yi it a4- ~ ; -~ .
r . r . .~
• adee~r ~ oeesestoih ~
fees. # tlwe ~ 1"see' ct ~
ti ~4lrewt~ P
`.~i is iolrrs~a at ~. ~ ~ ~'' ~ #
. +ioitar.i~dt. ~ ~ 1~loer Ys6ida Ie''eraa A~cL ~ ,!
-'.', a .. ~'''~ • ' .= s• .. : ~` : • fin s. , , .
'~ •. ~ ffi ccouiiier~o~ of ike lamb .~iowx~t d pip,
I~s•taeelt •s ~ - . •
. Ms~its !e' i+e
- , ' . lioiLele#a area ~ sta~eet of f~leoi ~7- Prolr~~ioet ioe~~,~ ~ .
• ~ ~~ ~
• '. +~'~"~ Orr siirrtlW tour iie
. • ~•: - ~~ ~iweses P~-, far *!'~.~3' ~ .
. • ~~ L
£ • ..L:. . ?~+;++„ '~'•T ~ ' .... art a-%" ~frr~i
. a
_ '
.., ~ No-~iaih ~~1e for a~o~d ~e ~t ~ ~, worm bo ire
,~ ~~ .,~
~ soi the ~t ~~, C. Jf a ~', ~
s!l'scti~e ~ ii s ~caart of c+oeopatsst ~ lw sot +~lerad or ~ boe~ ate
. seadersd P at ~ Aet iosrE#~dr~teoanfcr~ab~,~ to des ors data d.4ilr Ast.
if s#~ar tbir tl~iectfrs ~a~s of ~ Act s court of totapee~si~ deda~ cr irs,j
~ ~ +at ffiis Act or a~attaaahk b male a fie pnt, ae , ~,
Pmtpuyade ark x~id a tbriaa t6a t~ +~' die, ~,u ilra r
s~ ~ ~ suci s,~poa+olt d flee dower sr is
. ~ Ieeeeea~eoe Lao:)f ilea y ftds ~set~eiss t~ea~blr ~,
that sr+e fais~ r aw~er ~ ~ ~' be t by tba Csw~yp~
. •. .
,4 -
~~.~.:~ i
• ,r ..•~
~ _
~~
„~. .. , ~
~.
~,aoo ~ Dye.
~ •• ~..
#,~ ~~,
!~~• ,
lO,g9p . .
li9,0A0 .
1Q,,OOII
l~a90
l0,190iD .
!~ .
P72 2,3190
2.3019 ?,S,pp
2
500
Sa0t919: ~
S0 93,000
9S
p>t9
• ~0 .
~St919~ X0190 Sd ,
! 5~9pp
9~S T,3t94
2,340 2.300
Z
SO4
~~ _
~~ 9S,0pp
95
q'90
~ 2+30D ,
?,3pp ~ ,
95.040
~ 91,000
. -.~._
....~ .._ .... 4 • ~
• ..• . .
~
•
• ~ ... ~ Imp 1 _ ~
. .
~
~
P53 .~ ~.ObO lS,OQ~ '
~ ZS
r _
-
~ ~
~P~D
9?~S!
1, ~ l~pp
' ~~'
33
A63 !gyp !~
!~ .OGO
~
• p~} !~ ~~
.
!
~ ~~ 3S.
~b ~ !,~ • '
~~ 3S
• 33
.. ~ 2
300
~ ,
S~fl00
~~
• 'ire ~ew~ meows ~ ~
.. avaairat ~t ~ ~! ~ ~ +rt d Cq+~~r ~ R
'` ' 9~r ~ ~~ #bt iii ~t ~M~tsi~p
~! ~~•~ a ~t~wni i~~taia~lr"~- W ~~I ~Yi~r i ~ ~
K~ re~wes 8~iwi~iiif ~ olUa~e~~, . ~
Mrie+tl~,~ad~oar~gr~ia~se~, . ~nY
• pYw~at F.girres uaddr~5 coil~a1e ~,~i,~ '
•..•T~• ~. ~ ~ Fsr I Ya~r . ~
.. ~ _ .33!!0 '~1,#~ ~!3 ~
-' ~`*'~'` ~ ~ 390 S ZS
_ .~ 9,Opp ! ~ 3A00 ~
~i .
~, ' '. ~ ~hO,pb I S~ f
.Y r. ~ ~ ~ ~ iCi~~ I ~~
. ~~
.$F
~.
D,1V
. 91i
D,91I,#t
9:
AW
D,I1,3Y
l
s" _ _. - ".jam..: •.f ~~
i
• ~ .-, L
• • ~ -
• ~ .. .
. . ; i #~ "~i # ~" ~ ~ ie ~ a~ ad~liOOli ; .
. i~iopu lk~tlles i ~11d a~rte lydw+eAe ~ appWa~iap atlre ooite~uabi~ l~fost ~eios-b ilrit
Tl A dMdndibie.dsl~~ ~ aeaped b wa~a ~ ~ ~ i~ar i6e rrMi i....i sac
~. L. Ysa_~wr.d tit baeeie ae ~ far arr~i roi i~rafyi~ wirc s
• ~ p~ arl~ pry ~. cast or 1fM arsaypaq-wi ~udnr
. aadtr ttti M >aaaiiaaas >r~ ilMe l~aoay+lTa~ia aitl~iaiar YeLidr Act.
. F. You•laae oartt5ii ~ btaat~ ar ad+ratages ata aMo s+rati~ia far medc ian osier a prl~e +or
. : ~ ~. , ~seP, saemct ar a11Mr aa~twt..Tlis saripan~,1- +~ ait~c+e pgrs~t tatd~er ~ •~
• coeerape fe acooiieseoe ~ tlra ~ NaFS,it 1~oeor Yd~ide ~oraace Act. .
•` ~ ~ ~ ~ ii. liege Parts A sad ~ 6 aaeaa~le to tlrr aeaie~ Yr~sl~. ~ ~ i
b ~otsawrd iee~eei
. • ~. ~ ~ 1~ ~ pt~ d aQe ~eic applies l01Pede iaet #iih b bdh- ~--
. ~~ ~ ~:
'y
• 'f • ~• V
• •~f • ~ •• •, ~ t ~ -
• / ~ .~ ~ •
. . •~1
_~
. .'.~. ~. 'a.
~ r~
~. ~+
ASK b$2p.1N ;~s~;.'. •n,
:.b
'.;r` t
. ..~.
. ~a.; F
..n=@•
08/13/12 14:16 JFA% 6103615719
appAtJ1CMNN ORTHOPEDIC N'T~- LTD
Dsnl~ P. + p- ~D.
A.
Cori M. Davie. PA~. phi;(T1~ ~i11Z
i Dunwoody Or Fax: (717
CarliNe. PA 1701 S
OFFICE RECORDS
VWesr, David D'Od:03127/1954 Account a: 46118
p0liiB11Z OFgICE VI~T:
CHIEF CO#NPLAINT: Shoulder Pain. bllabeRl.
This is s r-old of Dr. Borr4r who s~ hf for
HiS'rORlf OF pRE3ENT ILLNESS: tttrfwd oNer end c aM1 M M- s T12
e;Mgcm of his sttopklere. in 1l=~. frle ~ af+M bo ~ • iar ~ ~ ~'
POr~q,ppic. Fie has been very ~ovdHs dow tl+lt~s ®row~i tla. Mr~t. HaRw~rat' 1o qat ~- ~ ti~~
ami ~ arcxmd tiMer+s rery wise ~ Agyr kMd ~
to get ht the t~hroorn~ end in and out of ohak, and wMh aN ~ +ot d1Ey e~~ 1
ai the pars0iiphhi is Cotttpisle. 11e ~ not IHnni _
upainnent since tin~ss thtte he M-eM to ae. a ~ ~~,
doirty Meer ediation of certetin areas of tfte spine that r4!d~ ~P
i~ps. The more M hiss his erms, which fa p~attY • bo
pent. K doss wake hint when he ptnna at tf~s. He e~ sk down ~ t7l~x. lta '~ >rd
taiw wand dos ao# want any wrPerryy because ht tines note ~, ~~ foi
a,~ ~ daily ~ring and waMd not 81ee is ~ ~ sttrrer~t
He ties anal Y
prosduts doM an dw ehouhleas. He has iM p 1Milal ~ a~a'a
Icagg t~im~~e. He is mattt~lid and M cwaaialsl on t+tH
adslb~on. He figs n ~ ~ ~ athsr Probklna~ Hs . vase 1
now ~aM~nL 1~ ~of aig~ ~~'~ asi ii sA r
hM sack and a traurnetlc am and ~ diseas. ~ ~ shoe a history of . H
h ~y for a taleeding d ~ u tract ~ whleat b nd uauattal ~ Ms
iai~a~oA, Icwnay stones, 1;he sheet a 9ro
~# chest Pain wlt~b any well >rs ~ diosna~ a has to rely upon
c~sal. i wer<t over his varaous sIMrS
hs lea ~~ infAeil end N+t•ra«i
PHYSICAL SXAMiNAT1ON: On examinatbn h hiss ~r1~sar end thfa s sfro~rt nadai
n~a to ts8c tv~who Is inn of the cis fu11. of ntvtlon +r~'tlw is buc h
wheelchair. nerrrwl sad tli+uaf adf aired b'n
does have a distu~ calck and Win In both shwulders ~haa no ~dertNae of the braQhial plea
elawated poslNort. Ciroula The io~ver extrernon ~ wens not ~m~'
auc~a, and no adenoPathy.
t otltNt and sat~taad~l inlarn~ a~ ex~nai *ingl
X,rays show a satisfaa cry
bent' erosbn~ in+Pl+agement wt bons or~rae AC rthtopathy~ ~whlehp i~Pood bit onWidR silo.
fosse ie anatomicsly norrnai. He does
ASSEgSMaNT: 5houider pain witt+ AC aafhropathy- prssumaby soh tiistis Injuries atttltiafnal to n
cuff.
to than Hs wIU let ~ know it thst ii not use
p~AN: He never had an inleation• sn°~we are goittp try ~ he tray na ~ a ~r sur0i
Inbsrnvention but ~ wen wee wo~~uW c~i~~ wan=gam an Miti of his shoulders.
With the pa#M+t in the sittlatg position bofh shoulders w.n P alsoltol r
PROCEDURE; .Then 4 n>t. Of GNsto~ne IS regiaa~ #nd 4 mL o7 ttX MaatlN~e 17~ Pl
BsRadhte ursder sterile teehnlcue 7+o twr ante
were injected, half intro the let{ shoulder and half lam the rift s u He tol d It weN-
002
WLtit?HT: 2Zfilti HEIGHT: 72 irtchss
BMi: 29.0 BLOOD PRESSURE:'29.8
CURRENT MEDICATIONS: Levothyroxine 50 mg qd, Omeprnole ~ mg twice daily. Ctiuccsami Plus
MSM 1500mg lid
ALLERr3lES: PenicUtin. Daevon~ phobic
Continued
E~HiE1iT B
08/13/12 14:16 FA% 6103615719
LI ~ ~ vid'YNser
Ci ~ , 06-9!<l1 Z
F~ ~ ~ ~e 2
:il~
Mit vital: NIMRied.iives With: P~rtilOC 17co1tPs~n: Est L.OMiM.M4~k~~~ •
-~ irk YMfFJts~Rtietbns -can only petlonw earl~r jslda.
p ~ : ~1 }hblla: C ppnnaa11~~ Uso: OenNie lpi~o Yar.Ci~
a I ~i~ae Tobacco: Dentes Smolopless Tobadi:o tJ~'sJltootaakk 1~1~o~•tNup Eir
C~: nies~~~ Use.
f ; ~ riewsd, no changes.
F ~ ~ tt}I:
A i tdlcal PTO6~N1ns'
~;; is~,optMtOeal tea Dt6sase (GCRi)1, Rt+ot~Ch Ukeira. C~astrokNMt~ e
,I i ~ xtdeats:
N I I /A - 3WgZ
it ~ ~ -Rack
I ~ 1 Hoc:
i ~ ~oles~st~cton~r. Wtdo~o ry, H~am~oe~fioidscto~tlY. Ruk fit, KaN Sa. Mte~ Firgar sx
-~ tsisEM+s tlevtoes: Manual Mrhs~loha[r Is used to andtulste
1~, viewed, no chanpea.
1 ~ i' d plsease.
~. ~ ;esdinp Dlaorger, 7'hYroi
~; oWawed, no ehanlles.
i ` N: Osn syn+Ptoms-
1. R~p ~ ~ srmptoms-
~ : ~U : U~i+aporbt tnfec~ion, kidney stones and t UTI's.
i ~ hncub: numbnMS. joint ptln and joint i~isss•
~; kin: Dades skin, haa~ r~ sYmP'~n":-
leuro: lres Panw sis.
sych: y s M~n~pg c~stlmptiwns.
~ ~IIsr~RyA M ono: DsnMs stls~ic7immunologk: sy~r~orns.
tenfwed. no changes.
"hotnas .1. Groen, M.D.
~ 003
:c: Douglas Bower MD
'JG~ts
tTo:12i~5693763
O~~t':PA$120
1210:43:07
Requested 8y: GBpMfCBAL
Report Status: Transcribed
Free: State Farm Fax: Statee Farr ICO#X~ at: ~LTI-21-2312-1b: 46 Dae: 148 Pager.
Wound Care Centtr H!s{~y and Priysi Coid:
CARLI$I.E REGIONAL MEDICAL. GTR Pa9
361 ALEXANDER SPRING RD
CARLISLE PA 17015
Pat Nbr: 1224863 W13ER, QAVID
DOB: 03127!1954
Roq By: HARDESTV. JAMES L
Med. Roc: 0001111514 Pat Type: OJ
Typo: MED Dict.: 05.~17f201215:34 50455796
Physician: HARDESTY, JAMES L
Admit: 05JOZ.'2012 08:00
Gender: MALE
Diaeharpe: 05131/2012 08:00
Location:
Transcribed: 05!1812012 02:54
DATE OF VISIT: OS/OS/2012
REASOA FOR P,DMISSZON: Mr. Wiser is referred to see us for evaluation of a
longstanding heel ulcer.
HISTORY OF PRESENT ILLNESS: Mr. Wiser is a 58-year-cld mar, who was i.nvolv4d
in a motor vehicle accident in 1982. TY.is resulted in a fracture of his
spine with paralysis. He had done fairly well until about 3-5 years ago
when he developed an ulcer on his left heel. Ee has been treating it
hir:lse]f for. the most part withav*_ total success. The wound remains open. He
has not had any fever or chills. There has been moderate drainage fro•n the
wound.
PAST MEDICPI., HISTORY: Significant for the above mentioned paralysis. He
has hypotryzoidism and Harretts esophagus and anemia. .
CtJRREi+tT NBDICATIONS: ~Tnclude Syrthroid and omeprazole. He takes
glucosarnire.
ALLERGIES: IICCLL'DE MOBIC, DAI2VON, AND PENICILLI*1, WHICH GIVi3S HIM HIVES.
PAST ST7RGICAL HISTORY: The patient had a back fusion in 1982 after his
accident. He also had back surgery in 2002. He has had a hemorrroidectomy,
cholecystectamy, knee surgery, and an amputation of his right inaex fir<cer
after.an accident in 1980_
SOCIAL I31S't'OP.Y: The patient is :Harried. He lives at home with his wife and
family. He is a nonsmoker, does not use alcohol.
FAMILY H7STnRY: Noncontributory.
REVIEW OF SYSTEMS: GF.~NERAL: The patient has not had any recent weight
changes. He has had no night sweats or fevers. HEENl': He denies any
history of seizures. He has not had any blurred vision, double vision, o.
loss of vision. He has not had any problems wish sinusitis or nose bleeds.
~: ~
To: 12195690765 Fraa:State Farce Fax:Btate Faro KtYPA7C•3 at:3Ult-21-2012-16:48 Doc: 148 Paq :003
FiaportPAQ1Z0 Wound Car® Center H1:t and Phys6 Co' : 8a8
081081201210:43:07 GARlISLE REGIONA! M~1CAL CTR Pa e:x
tiequested By: CBOMICBOi~ 381 AlEXANDSR SPRMIG RD
CARl13lE PA 17015
Report Statues: Transcribed
Pa! Nbr. 1224683 WISER, DAVID Admit: 05!0212012 08:00
DOB: 03127/1954 Gondar. MAZE
Req By: NARDES7Y, JAMES L Discharge: 05/31.'Z012 08:00
Med. Roc: 0001111514 Pat. Type: OJ Looation:
Type: MED Dkt.: 05/47/201215:34 50455796 Yranscr[bed: 05lt8/2C1202:54
Physician: ' HARDE5TY, JAMES L
He has no difficulty swallowing. He does have a history c£ Barretts
esophagus. RESPIRATORY: Denies wheezing, asthma, or c2.•ronic cough.
CARDIAC: He denies chest Hain, galpitatians, or paroxysmal nocturnal
dyspnea. C3ASTROINTE3TINAL: As above, he has Barretts esophagus. He
denies abdorni.ral pain. He has not noted any recent melera ar hematcc:'~ezia.
GENITOURINARY: "_`he patient self catheterixQd. He has not had any recent
problems with malodorous urine. He does have a history of kidney stone,
which ig nonobstructing. L(OCOMOTC)R: The patient is paralyzed from, I
believe, ii2 down. He has no history of phlebitis or deep venous
thrombosis. SNU4CRINE: The patient denies diabetes. He does have mild
hypothyroidism. NFUR(7FSYCHIATRIC: The patient is a well adjusted. He
works part-time in a local member stare. He has no thoughts cf se.l.f-Y:arrr..
FHYS I CAL EXAM I NA'P IOlri
GY'NERAL: Reveals a healthy-appearing muscular man in no acute distress. Fig
stated height is 6 feet 1 inches. His weight is 220 pounds.
VIT?.L SIGNS: His blood pressure is 136I81, heart rate is ].03, and
respirations are-18. Has temperature is 97.9 degrees.
HEBNT: Head is norrnocephalic, atraumatic. Pupils are equal and reactive to
light. Extraocular movements are intact. His sclerae are anicteric. Nose
and throat are clear.
NECK: =Supple. -There is. no cervical tenderness. I do not appreciate any
thyroid enlargement. There are no cervical masses.
CHEST: Clear to auscultation. 't'here is no wheezing, rates, or rhonchi.
HEART: Reguiar without significant muraiure, rubs, or gallops.
AHD4ME2d: 'Soft. Eawel sounds are normoactive.
EXTREMITIES: Warm. He has ,2~+ edema of both lower ex.~remities more sa on
t!~e left than an the right. This is a relatively new pe: the patients
'3€~2512Lfl~?
,
Tn:121~s690765 Fran: State FarA Fax:3tate Fars KOFAX~ at: JUd-2]-2012-I6:4i3 Qoc:148 Pays
Rv~ort:PA6120 Wound Cars Ceretar Hiat~o and Phyyai Caic
0810$1201210:43:07 CARLISLE kEGiOIVAL ME~CAL CTR Pa
Raquestad By: CBOMICBOL 361 ALEXANDER SPRiN(3 RQ
CARLISLE PA 17015
Report Status: Transcnbed
Pat Nbr: 1224663 WISER, DAVED Admit: 05/0212012 08:00
DOB: 03127!1954 - Gender. MALE
Raq By: HARDESTY, JAMES L Discharge: 05/3112012 08:00
Mad. Rec: 0001111514 Pat. Typa: OJ Location:
Typs: MED Diet.: 05/171201215:34 50455796 7ra~scribed: 05/i8120t2 02:54
Physician: HAROESTY. JAMES L
history. Gn his left' heel, these is a fairly Large but relatively
superficial ulcer with a lot of necrotic debris. It measures at least a 3 x
5 ern. The periwound ti3sues are intact. There is no undermining and the
wound does not probe deeply. Pedal pulses are difficult to appreciate. I
feel a dorsalis pedis. I do not feel a posterior tibial. AEIs were
calculated at about 1.0.
IMPRESSION: A pleasant 58-year-old man with a longstanding heel ulcer by
history never been deep, but it has been present for several years. We
discussed today the importance of offloading. There is some necrotic
debris, wP.ich will debride today. We also discussed something that try to
minimize his leg swelling as this has been a problem. I thiYik it would be
reasonable to go ahead end get an ultrasound of his leg to rule out acute
DVT in light of the fact that the leg has been more swollen over the past 2
weeks. Clinically, it does not seem to be the case, but I think it would be
important to rule that out and then finally today with the patients
perrtissiora, we did use a #10 scalpel and forceps to debride his heel, a
moderate amount of necrotic skin was debrided from the periphery of the
wound. The wound bed was lightly abraded. It did bleed but only minimally.
wounds were cleansed. We will apply a collagen based dressings and plar_ to
see thf patient back in one week. ;i4e will follow up his ultrasound as an
outpatient.
James L Hardesty, MD, fiACS
DD: Thu May 17 15:34:21 2012
DT: Fri May 18 02:54:05 2012
50455796 ($6163
CC:
THIS DOCUMENT TS NOT A LEGAL COPY UNLESS SIGNED
:004
;858
1e:3
To: 12155690765 Fros:State Fars Fax: State Fars KOFAX~? at:dLN-21-2012-16:48 Da:148 Paq :aQS
Roppoart:PAB120 Wound Care Center History and Physi Coi :858
06f08 201210:43:47 CARU$LE RE610NA1. MEDICAL CTR P ge:4
Requested By: C80MlCBdL 361 ALEXANDER BPRINf3 RD
CARIIS~E PA 17015
Report Status: Transcribed
Pat Nbr: 1224683 WISER, DAVID Admit: 05/02/2012 08:00 '
DOB: 03/27/1954 Gender: MALE
Req Sy: NARQESTY, JAMES t DlacharSe: 05131/2012 08:00
iYted. Rea: 000111':514 Pat. Type OJ Lacatlon:
Type: MED Diva.: 05/17!201215:34 50455786 T'ranscrlbod: 0511 8/201 2 02:54
Physician: HARDESTY, JAMES L
DICTATED/TRAN''CRIBED
•
s
PENNA. N0.FAULT MOTOR VEffiCLE INSURANCE ACT
~ 106
gavttnmeatal and private entfiies and individuals, and fs~rm and
operate or authorize the formation and operation of bureaus and other
legal entities.
(b) CANCa~.AaoN, REFIT:AL To RarrEw, oR oT~ rasMnvATION of
n~ravRwNC6.-Cancdlstion, refusal to renew and other termination of in-
sivance shall be provided for iR socordance with the provisions of the
act of June 5, 1968 (P.L. 140, No.78 ), eatitlal "An act regnlatiog the
• wrfiing, cancellation of or refusal to renew polides of antoinobile insur-
ance; and imposing powers and duties on the Insurance Commissioner
therefor." .
Comment:
Cite as 40 P.S. § 1009.105.
The Act of 1988, refereed to ni (b) will be found in 40 P.S. § 1008.1
- et seq. -
§ 106. PAYMENT OF CI.AII1t8 FOR NO-FAULT BENEFrI's.
(a) IN cElvESAL.-
(1) Nofault benefits are payable monthly as loss accrues. Loss
accrues not when injury occurs, but as allowable eacpense, work loss,
' replacement services loss, or survivor's loss is sustained.
(~) No-fault benefits are overdue if not paid within thirty days
after the receipt by the obligor of each submission of reasonable proof
of the fact and amount of loss sustained, unless the obligor designates,
- neon receipt of an initial claim for no fault benefits, periods not to
exceed thirty-one days each for accumulating all such clam received
• ., ~ within each such period, in which case such benefits are overdue if not
paid within fifteen days after the close of each such period. If rea-
sonable proof is supplied as to only part of a claim, but the part
- amounts to one hundred dollars (;100) or more, benefits for such part
are overdue if not paid within the time mandated by this paragraph.
An obligation for basic loss benefits for as fiem of allowable expense
may be discharged by the obligor by reimbursing the victim ~ by
making direct payment to the supplier or provider .of products,
services, or accommodations within -the time mandated by this para-
.graph. Overdue payments bear interest at the rate of eighteen per
cent (18%) per annum.
17
~~`
`. ~ ZOG S1iOR1' 7117.E, Pi1BP05E AND DEFINITIONS
(S) A claim for no-fault benefits small be paid withoat deduction
for the benefits or advantages which are to be subtr&ted from loss in
calculating net Mss iE sudz benefits or advantages have not been paid
or provided to sash dart prior to the date the nofaak benefits are
overdue ~ the no-fault benefits damn is paid. The obligor is there
upon eatfiled to recover re~ from tl~e person obligated bo
pay or provide such benefits or advantages or from the claimant
who actually receives them.
C4) M Igor may bring an action to recover reimMusemwt for
no-fault benefits which are paid upon the bates of an intentional
station of a material fact by a claimant or a supplier or
provider of an hem of allowable expense, if such obligor reasonably
relied upon sncls misrepron. The acdon may be brought only
against such supplier or provider, unless the claimant has a~tention-
aIIY. mientai the facts or knew, of the misrepresentation. M
obligor may offset amounts he is entitled to recover from the claimant
under this paragraph against any no-fault bene&a otherwise due.
(5) M obligor who rejects a claim for basic Ions benefits shall
give to the claimant writt~ notice of the rejection promptly,'but in
no event more than thirty days after the receipt of reasonable proo#
of the Loss. Such notice shall ~cify the reason for such rejection and
inform the claimant of the terms and cond#ions of his right to
ob#ain an attorney. If a claim is rejected for a reason other than that
the person is not entitled to basic loss benefits daim«I, the written
notice shall inform th6arlaimant that he may fiTc his claim with the
assigned claims bureteu-~d shall give the name and address of the
bureau.
~ 1) ]r' ZCept as y.~lrovided in this sabSeCtiOn, nO~fault
benefits shall not be deai~~or terminated because the victim executed
a release or other settlement ageement, A dsian for no-fault benefits
may be discharged by a settlement agreement for an agreed amount
payable in instalhneats or in a Lump sum, if the reasonably anticipated
. net low does not exceed two thousand five handred dollars (#8,500).
In all other cases, a claim may be discharged by a settlement to the
extent authorized by law and upon a finding, by a court of competent
jurisdictiion, that the settlement is in the best interest of the claimant
and any bene$ciaries of the settlement, and that the claimant under-
stands and consents to such settlement, and upon payment by the
PENNA. NO-FAULT MOTOR VEffiCLE INSURANCE ACT
' _ •' § 106
restoration obligor of the costs of such proceedings indndiag a
reasonable attorney's fee (basal upon actual time expeaded) to the
attorney selected by or appointal for the daimant. Such cysts may
not be duuged to or deducted from the proceeds of the aetdeelmt.
Upon approval of the settlement, the court may malae appropriate
orders concerning the safeguarding and disposing of the proceeds of
the settlement and may direct as a condition of the settlement agree-
ment, that the restoration obligor pay the reasonable coat of ~ap-
• propriate future medical and vocational rehabilitation
(S) A settlement agreement for an amount payable in install-
ments shall be modi#iai as to amounts to be paid in the future, if it is
shown that a material and substantial change of circulr~stances has
ocxurred or that there is newly-discovered evidence g the
claimant's physical conditmn, loss, or rehabilitation whidl could not
have been lonown previously or discovered in the exercix of reason-
able diligence.
(3) A settlement agreement may be set aside if it is procured by
fraud or if its terms are unconscionable.
(C) TIME LIMITATIONS ON ACTIONS TO RECOVER BENEFII'S.-
(1) If no-fault 6ene$ts have not been paid for loss aliailig other-
wise than from death, an action therefor may be coinilieneed not
later than two years after the victim suffers the loss and either lrnows,
or in the exercise of reasonable diligence should have laiown, that the
Loss was canned by the accident, or not later than four years after the
accident, whichever is earlier. If no-fault benefits have been paid for
loss arising otherwise than from death, an action for further benefits,
. other than survivor's benefits, by either the same or another daimairt;
may be commenced not later than two years after the last payment of
benefits. '
(2) If no-fault benefits have not been paid to the deceased victim
or his survivor or survivors, an action for survivor's benefits may >te
commenced not later than one year after the death or foar years after
the accident from which death results, whichever is earlier. If anr-
vivor's benefits have been paid to any survivor, an action for fuuther
survivor's benefits by either the same or another claimant may be
commenced not later than two years after the last payment of bene-
• 19
~O6 SHORT TITLE, PURPOgE AND DEFINITIONS
,- Sts. If no-fault benefits have been paid for loss suEend by a victim
before his death resnlting from the i,rjury, an action for survivorta
benefits may be not later than one year after the death
or six years after the last payment of benefits, whichever is earlier.
(S) If timely action for basic restoratbn benefits is commenced
against an obligor and benefits are denied of a detation
that the obligor's coverage is Wert applicable to the claimant under the
provisions of section ~4 of this act, an action against the applicable
obligor or the obligor to whom a edaim is assigned under an assigned
claims plan may be commenced not later than sixty days after the
determLratim- becomes Seal ~ the last date on whie~ the action could
otherwise have been commenced, whiedtever is later.
(4) Except as paragraph (1), (S ), or (S) ~ a longer
period, an action by a claimant on an assigned claim which has been
timely presented in accordance with the provisiions of section 108 (c )
of this act may not be commenced more than sixty days after the
claimant receives written notice of rejection of the claim by the
restoration obligor to which it was assigned.
~(5) If s person entitled to no-#ault benefits is under a legal
disability when the right to bring an action for -the benefits first
accrues, the period of his disability is not a part of the time luaited
for commencement of the action.
(d) 1LSSIGNMENT OF HBxEFrrs.-An assignment of or an agreement to
assign any right in accordance with this act for loss accruing in the future
is unenforceable except as to benefits for:
(1) work loss to secure payment of alimony, maintenance, or
child support; or
(2) allowable expense to the extent the benefits sre for the exist
of products, services, or accommodations provided or to be provided
by the assignee.
(e) I~ovcriox exn ssmFF.-Except as otherwise provided in this
act, basic Ioss benefits shall be paid without deduction or setoff.
(f) EREMPTION OF BExEFII'S.-
(I) No-fault benefits for allowable expense are exempt from
garnishment, attachment, execution, and any other process or claim,
20
CONSENT OF INSURED
I, DAVID E. WISER, an adult being of sound mind, do hereby declaze as follows:
1. I have agreed to accept alump-sum payment of Six Hundred Thousand
($600,000) from State Farm Mutual Automobile Insurance Company in exchange for a full and
release of State Farm's obligation to pay any further No-Fault Benefits of any kind
arising from my Mazch 4, 1982 accident, contingent on this Court's approval.
2. I understand that as a result of this settlement, State Farm will have no
responsibility whatsoever to me or my estate for No-Fault Benefits arising from my accident
Mazch 4, 1982.
3. I understand that "No-Fault Benefits" in these proceedings means any and all
that were, aze, or would have been payable under the No-Fault Act and/or the applicable
insurance policy, whether for medical expenses, caze, accommodations, equipment,
medications, home renovations, modifications, repairs, upkeep, insurance, transportation, andlor
other expense for any purpose, of any kind, nature or type.
4. I believe the settlement is in my best interests and those of any beneficiaries.
5. I understand that this is a full and fmal settlement and I expressly agree that it
not be subject to modification or change in the future under any circumstances.
6. I have been advised by State Farm of my right to be represented in these
by an attorney of my choosing at State Farm's expense, but have chosen to proceed without
attorney.
7. I have not been asked to pay any of the costs of these proceedings.
\\bbsdocs\CPShare\CPW inlHistory\ 120810_0001 \8388.12
EXNISiT E
I understand and agree that the settlement proceeds aze intended to be used to
any future medical expenses or other expenses of any nature I may incur which aze causally
to the injuries sustained in the subject accident.
9. I further understand and agree that any such future medical or other expenses
be compensable under any applicable Medicare or Medicaid coverageand/or, if paid by Medicare
Medicaid, may be subject to a claim by Medicare or medicaid against me for reimbursement. I
understand and agree that State Farm shall not be responsible or liable to reimburse Medicare
Medicaid for airy such sums, and that I shall indemnify State Farm for arty such sums whic~l
Farm is compelled to pay in accordance with the terms of the General Release attached to the
Petition as Exhibit ~G" which I will execute in connection with this settlement.
10. No promises, considerations or inducements, other than the promise to pay the
stated above, have been made to me in connection with this settlement.
11. Upon receipt of an Order from this Court approving this settlement in the form
Order attached to the petition as Exhibit "F", I will sign the General Release attached as
"G" in exchange for the settlement funds.
12. I have not been placed on notice of arty Medicare or other governmental liens,
hereby represent that Medicaze has not paid arty expenses causally related to the subject accident..
13. I have read the Petition to which this Consent is attached and find the facts
thereinto be tnrth and accurate to the best of my knowledge, information and belief.
(NOTARY SEAL) ~ `
.11, ~~,
c
DAVID E. WISER
\~bbedop\CP5hare\CPWinlHistory\120716_000118388.08 10
STATE FARM MUTUAL AUTOMOBILE COURT OF COMMON PLEAS
INSURANCE COMPANY CUMBERLAND COUNTY
One State Farm Drive
Concordville, PA 19331-0041
Petitioner CIVIL ACTION -LAW
v.
NO:
DAVID E. WISER
333 Crreenspring Rd.,
Newville, PA 17241 .
Respondent
ORDER
AND NOW, this day of , 2012, upon consideration of the J
Petition of petitioner, State Farm Mutual Automobile Insurance Company and of Respondent,
Wiser for approval of alump-sum settlement of David Wiser's No-Fault Benefits and after a
and for good cause shown, the Court makes the following findings:
1. The accident giving rise to this Petition occurred on March 4, 1982.
2. At issue are No-Fault Benefits under the former Pennsylvania No-Fault
Vehicle Insurance Act of July 19, 1974, No. 176, P.L. 489, 40 P.S. § 1009.101, et sea. ("No-F
Act") (repealed by the Act of Feb. 12, 1984, P.L. 26, No. 11, §8(a), effective Oct. 1, 1984) to
Mr. Wiser is entitled as a result of the subject accident.
3. The proposed lump-sum settlement is in the best interests of the insured,
Wiser, and those of any beneficiaries.
\\bbsdocs\CPShare\CPW in\History\ 120810_0001 \8388.12
EXMN~T F
r y
4. The settlement does not appeaz to have been procured by fraud, and its terms aze
unconscionable.
5. Mr. Wiser has been made aware of his right to be represented in these
by an attorney of his choosing at State Farm's expense, but has chosen to proceed without
counsel.
ACCORDINGLY, THE FOLLOWING ORDER IS ENTERED:
1. The Petition for approval of lump-sum settlement of No-Fault Benefits pursuant
40 P.S. Section 1009.106(b) is APPROVED;
2. State Farm is released from any and all further obligation to pay No-Fault
of any kind, as of the date set forth in the Petition;
3. The settlement is full and final, and shall not be subject to modification in the future;
4. State Farm is authorized to release the settlement consideration to Mr. Wiser
restriction, upon receipt of the signed Full and Final General Release in the form attached to
Petition; and
5. State Farm is directed to pay all costs and fees associated with this proceeding,
addition to the settlement proceeds and not as a deduction from same.
BY THE COURT:
\\bbsdocs\CPShare\CPWin\I-Iistory\ 120810_0001\8388.12
FULL AND FINAL GENERAL RELEASE
THIS RELEASE is made by David E. Wiser ("Releasor") in favor of State Farm
Automobile Insurance Company, its successors and assigns, affiliated corporations and
and all of its agents, employees, workmen and servants, and all other persons and entities
collectively "Releasee").
IN CONSIDERATION of the sum of Six Hundred Thousand Dollazs and No
($600,000.00), and other good and valuable considerations, Releasor, for himself, his estate,
beneficiaries, executors, administrators, and assigns, does fully and completely release and
discharge Releasee from any and all claims, expenses, benefits, suits, causes of actions,
damages, interest, demands, and costs, whether known or unknown, suspected or
foreseen or unforeseen, liquidated or unliquidated, against Releasee which azose from an
on Mazch 4, 1982.
Releasor further represents that there aze no unsatisfied liens or reimbursement right by
hospital, ambulance service, or other medical provider, Medicare, Medicaid, the Pennsyl
Department of Public Welfare, insurance company, or attorney enforceable against the proceeds
this settlement or against the Releasee, any insurance carrier or the persons, firms, or
making the payment herein. If such a lien or reimbursement right is asserted against the
herein or against the Releasee or against any insurance carrier, or any person, firm, or corporal
then, in consideration of the payment made to the Releasor herein, Releasor covenants to pay
satisfy such asserted lien or reimbursement right, or to satisfy the same on a compromise basis,
to obtain in any event a release of the Releasee herein, insurance carrier or any other persons, fi
or corporations, and to defend, indemnify and hold harmless Releasee from any costs, expen:
\\bbsdocs\CPShare\CPW in\History\ 120810_0001\8388.12
aE'1tB~T G
attorney fees, claims, actions, judgments, or settlements resulting from the assertion or
of such lien or reimbursement right by any entity having such lien or reimbursement right.
Releasor agrees and acknowledges that he accepts payment of the sum specified in
Release as a full and final payment of No-Fault Benefits and that no further
whatsoever will;be made by State Farm.
IN WITNESS WHEREOF, I hereby sign this Full and Final General Release, intending to '
legally bound.
SIGNED, SEALED AND DELIVERED
IN THE PRESENCE OF:
WITNESS
DAVID E. WISER
DATED:
WITNESS
\\bbsdocs\CPShare\CPW in\History\ 120810_0001 \8388.12
r M
BENNETT, BRICKLIN & SALTZBURG LLC
BY: Curtis C. Johnston
I.D. No. 64059
222 EAST ORANGE STREET
LANCASTER, PA 17602
(717)393-4400
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY
One State Farm Drive
Concordville, PA 19331-0041
Petitioner
v.
DAVID E. WISER
333 Greenspring,Rd.,
Newville, PA 17241
Respondent
ATTORNEY FOR PETITION]
State Farm Mutual Automobile
Insurance Company
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
CIVIL ACTION -LAW
NO:
CERTIFICATE OF SERVICE
I, Curtis C. Johnston, hereby certify that I have this day served a true and correct copy of
foregoing Joint Petition for Approval ofLump-Sum Settlement of David Wiser's No-Fault
Pursuant to 40 P.S. Section 1009.106(b)on the persons listed below by facsimile and first
mail, postage prepaid:
David E. Wiser
333 Greenspring Road
Newville, PA 17241
(Respondent)
BENNETT, BRICKLIN & SALTZBURG LLC
BY: \~-~J
Curtis C. Johnston, orneys for
State Farm Mutual Automobile Insurance Co.
Date: ~/,y /~~ `~„
\\bbsdocs\CPShare\CPWinU-Iistory\ 120810_0001\8388.12
~ ~~
~/
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY
One State Farm Drive
Concordville, PA 19331-0041
Petitioner
v.
DAVID E. WISER
333 Greenspring Rd.,
Nevwille, PA 17241
Respondent
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
CIVIL ACTION -LAW
~S. ~~ v~ f
NO: ~a - ~~
ORDELR
AND NOW, this 'day of 'T , 2012, upon consideration of the Joi
Petition for Court Approval of Lump Sum Settlement of No-Fault Benefits, it is hereby
that a Hearing on said Petition is hereby scheduled for _~ ~ (~C:TO~j~, 2012 at ~'
14 • H • ~. in Courtroom ~.
BY THE COURT:
~~
J.
Thomas A. PlaCey
Common Pleas ~wdge
~'p~ ,,,~.`f~ot ~~ag~ a
N
r
#t-~
-~ ~,
w
-~
~r
-~~
~~}
_.~-
~~~
s
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY
One State Farm Drive
Concordville, PA 19331-0041
Petitioner
V.
DAVID E. WISER
333 Greenspring Rd.,
Newville, PA 17241
Respondent
COURT OF COMMON ,E =;
CUMBERLAND COL S) R ¢ "
CIVIL ACTION - LAV
NO:'
12 --Gl9S 3vtL Acmttogo
ORDER irk AND NOW, this day of 040b94._,2012, upon consideration of the Joint
Petition of petitioner, State Farm Mutual Automobile Insurance Company and of Respondent, David
Wiser for approval of a lump-sum settlement of David Wiser's No-Fault Benefits and after a Hearing
and for good cause shown, the Court makes the following findings:
1. The accident giving rise to this Petition occurred on March 4, 1982.
2. At issue are No-Fault Benefits under the former Pennsylvania No-Fault Motor
Vehicle Insurance Act of July 19, 1974, No. 176, P.L. 489, 40 P. S. § 1009.101, et se g. ("No-Fault
Act") (repealed by the Act of Feb. 12, 1984, P.L. 26, No. 11, §8(a), effective Oct. 1, 1984) to which
Mr. Wiser is entitled as a result of the subject accident.
3. The proposed lump-sum settlement is in the best interests of the insured, David
Wiser, and those of any beneficiaries.
\\bbsdocs\CPShare\CPW in\History\ 120810_0001 \8388.12
EJANI81T F
4. The settlement does not appear to have been procured by fraud, and its terms are not
unconscionable.
5. Mr. Wiser has been made aware of his right to be represented in these proceedings
by an attorney of his choosing at State Farm's expense, but has chosen to proceed without personal
counsel.
ACCORDINGLY, THE FOLLOWING ORDER IS ENTERED:
1. The Petition for approval of lump-sum settlement of No-Fault Benefits pursuant to
40 P.S. Section 1009.106(b) is APPROVED;
2. State Farm is released from any and all further obligation to pay No-Fault Benefits
of any kind, as of the date set forth in the Petition;
3. The settlement is full and final, and shall not be subject to modification in the future;
4. State Farm is authorized to release the settlement consideration to Mr. Wiser without
restriction, upon receipt of the signed Full and Final General Release in the form attached to the
Petition; and
5. State Farm is directed to pay all costs and fees associated with this proceeding, in
addition to the settlement proceeds and not as a deduction from same.
, k VeJ
stand ddit
101
\\bbsdocs\CPShue\CPW in\History\ 120810_0001 \8388.12