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HomeMy WebLinkAbout14-1737K. Lee Derr, Esq. ID# 71860 P.O. Box 841 Carlisle, PA 17013 (717)787 -3118 1 2 Gabrielle Grolier and ) COURT OF COMMON PLEAS FOR 3 Ava Grolier (minor), ) CUMBERLAND County, Pennsylvania 4 Plaintiffs ) 5 ) r7 6 ) u{- - 7 vs ) DocketNo. /t/ 173 7 i' `: :. 8 Charles Raffensburger and ) // / ! / 9 H L Stoneburger Plumbing, ) 10 Defendants. ) < -0 11 ) 12 ) C') —f 13 14 PETITION FOR LEAVE TO COMPROMISE MINOR'S CLAIM 15 16 17 COMES NOW, Gabrielle Grolier, the mother and guardian of Ava Grolier, by her 18 attorney, K. Lee Derr, and pursuant to Pennsylvania Rules of Civil Procedure 2039, and petitions 19 this Court to enter an order settling the above - captioned action, and, in support of the petition, 20 avers as follows: 21 22 1. Ava Grolier, who was born on January 17, 2010, and who is now four years of age, is a 23 plaintiff in the above - captioned matter. 24 25 2. Ava was injured on August 21, 2012, on Noble Blvd. in Carlisle, when the vehicle in which 26 she was a passenger was broadsided by a truck driven by Defendant Raffensburger. 27 28 3. Ava sustained bruising to her head and a concussion. Attached to this petition as Appendix A 29 is the most recent medical report from the minor's doctor. The minor is no longer under active 30 treatment for the injuries she sustained as a result of this accident. To petitioner's knowledge, 31 there are no medical or insurance liens or claims for subrogation in this case. 32 33 4. Medical expenses were incurred as follows: 34 Carlisle Regional Medical Center 2687.24 35 Div Pediatric Genetics 133.00 36 Harry Bramley, DO 428.00 37 MS Hershey Medical Center 78.00 38 MS Hershey Medical Center 89.00 39 Carlisle Pediatric Assoc. 153.00 40 Quantum Imaging 198.00 41 Cumberland Goodwill EMS 654.16 42 TOTAL: 4420.40 43 44 5. Ava is represented in the above - captioned action by K.Lee Derr who was retained by her 45 mother, Gabrielle. However, counsel is not seeking any remuneration, and instead has agreed to 46 represent Ava pro bono. /44.3- 75" ,� •a4 41r ? 9 ' 3 o337y K. Lee Derr, Esq. ID# 71860 P.O. Box 841 Carlisle, PA 17013 (717)787 -3118 1 6. Petitioner approves, on behalf of Ava, of the settlement of $6,000.00, as a full and fair 2 settlement of the above - captioned action, which fairly and adequately compensates her for 3 injuries and expenses. 4 5 WHEREFORE, Petitioner respectfully requests this Court to enter an order approving settlement 6 as set forth above. 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 DATED: ofi-c`L 1% c2e /4( Respec tted, y: K. Lee Derr Attorney for Petitioner K. Lee Derr, Esq. ID# 71860 P.O. Box 841 Carlisle, PA 17013 (717)787-3118 1 Gabrielle Grolier and ) COURT OF COMMON PLEAS FOR 2 Ava Grolier (minor), ) CUMBERLAND County, Pennsylvania 3 Plaintiffs ) 4 ) 5 ) 6 vs ) DocketNo. 7 Charles Raffensburger and ) 8 H L Stoneburger Plumbing, ) 9 Defendants. ) 10 ) ) 12 13 14 15 VERIFICATION 16 17 18 I, Gabrielle Groller, am the Petitioner in this action and hereby verify that the statements made in 19 the foregoing Petition For Leave To Compromise Minor's Claim are true and correct to the best 20 of my knowledge, information and belief. 21 22 1 understand that the statements in said Petition are made subject to the penalties of 18 Pa.C.S. 23 §4904 relating to unsworn falsification to authorities. 24 25 26 DATE: 3/ 17/ 4/ Ackibikalt J41.0-Let4 27 PETITIONER 28 29 30 31 To whom it may concern, 1 have been asked by K. Lee Derr, attorney at law, to write a narrative report regarding one of my patients AvaGnoUer. For the past seven years 1 have been the medical director of The Penn State Concussion Program and one of the pediatric rehabilitation physicians at Hershey Medical Center. | consider myself an expert in the field of traumatic brain injury. Ava has been a patient of mine since September 26,2012. At the visit, mom reported Ava was a properly restrained backseat passenger in a motor vehicle accident which occurred on August 21, 2012. Ava apparently hit the front part of head on the side window. There was obvious swelling and bruising noted on pictures that mom brought to the office. Mom indicates there was no Ioss of consciousness and Ava cried at the scene. She was evaluated in an emergency department and a CT scan of her brain was negative for intracranial bleeding. At that visit, mom clearly identified concussion symptoms, including personality change, complaint of headache, and difficulty sleeping. In addition, 1 felt some of her symptoms may havebeen post traumatic stress. 1 did make some suggestions regarding treatment, and had a foltow up appointment on November 7, 2012. At the November 7 visit Ava was clearly improving, but indicated some minor symptoms. It appeared mom had notice some cognitive change as Ava seemed to be somewhat confused with certain words when she speaks. She certainly was improving, but not at baseline. I suggested a follow up in 3-4 months, and if cognitive functioning still was a concern, would consider an evaluation from speech therapy. Avaba child who suffered a traumatic brain injury, h*cia|contusiona,an6posttraurnabcstress as a direct result from the motor vehicle accident which occurred on August 1, 2012. All appropriate precautions to reduce i 'uryxvenetahen,asthechi|dxvaspropedynestrainedinacar$eatandinthe backseat. Ava continued to have symptoms two and half months after the accident, however certainly she was improving. 1 do expect that over the next few months Ava will continue to show improv ment and make a full recovery. She should continue to grow and develop appropriately. 1 do not expect any tong term problems as a result of this accident. However, it is known that individuals with history of concussion may be more prone for future concussion, and this accident may have put Ava and increased risk for further injury in the future. Harry P. Bramley, D.O. • Outlook - leederr@hotmail.com SearcailReply Folders Inbox 27 Archive Junk Drafts Sent Deleted New folder Quick views Documents Flagged Photos Shipping updates New category Page 1 of 1 aeletRE:AAc lle Junk Sweep Move to Categories is To see messages related to this one, group messages by conversation. Bramley, Harry (hbramley @hmc.psu.edu) Add tc To: 'lee derr' Will print off and send to you . I will include this letter and my office visit notes. I am looking to see if I can include the bills as well. Will let you know. Thanks. From: lee derr [mailto:leederr @hotmail.com] Sent: Tuesday, December 11, 2012 5:49 PM To: Bramley, Harry Subject: RE: Ava Doc, looks good...thanks...can you also send the bills showing the total charged before any insurance offsets or do I need to contact another dept? K. Lee Derr, Esq. 105 Frytown Rd Carlisle, PA 17015 From: hbramley(ahmcpsu.edu To: leederr(ahotmai I.com Subject: Ava Date: Mon, 10 Dec 2012 02:48:04 +0000 © 2014 Microsoft Terms Pri® 014 191kneiepflrs T£inglish (lehilita4 Stalla*elopers https://b1u171.maillive.com/default.aspx?id=64855&rru=inbox Collab with C See how S Office 365 Online to i school a b Gel AdChoices i 3/21/2014 PENNSTATE HERSHEY lizT Milton S. Hershey RP Medical Center Harry Bram ley, D.O. . Assistant Professor and Medical Director Concussion Program and Pediatric Rehabilitation Tel: 717-531-6824 Fax: 717-531-0245 Matthew Silvis,M.D. Assistant Professor Primary Care Sports Medicine Concussion Program Tel: 717-531-5638 Fax: 717-531-0983 March 12, 2013 This is an update regarding Ava Grolier. I had the opportunity to see Ava in follow up on 2/27/13 with her mother. During this visit Ava was still suffering from symptoms of brain injury and post-traumatic stress disorder. Mom indicated Ava continued to be more hesitant when riding in cars, and was still having some nightmares. In addition, mom feels Ava continues to have difficulty finding words as compared to before the car accident. We discussed the possibility of a speech therapy evaluation and psychological evaluation. However, because she continues to show improvement we decided to continue to monitor. I did indicate mom should contact me to discuss if improvement does not continue or if symptoms worsen. Within a reasonable degree of medical certainty, these symptoms are the direct result of the car accident which took place on August 21, 2012. Because Ava was displaying continued symptoms, we scheduled a follow up appointment in 6 months. Harry P. Bramley, D.O. Penn State Milton S. Hershey Medical Center • Penn State College of Medicine • Penn State Hershey Children's Hospital Penn State Concussion Program, Mail Code H085, 500 University Drive, P.O. Box 850, Hershey, PA 17033-0850 An Equal Opportunity University GENERAL ���K���� "��x�u-n���"��u-���u_ Fm�mcono�emdnnof S0(THOUSAND DOLLARS AND O01O0 CLAN # 010171248841 ---- ---dollars `� �G,0O0.O ) receipt of which is hereby acknowledged, we release and discharge, and for representatives, executors, administrators, successors and assi ny' do hereby remise, release and forever discharge H.LGTONE8ERGER PLUMBING AND CHARLES RAFFENSBURGER hereinafter referred to as the releasee(s), his/her/their/its hairs, executors, administra/ors, insurers, successors and assigns, and any and aU other persons, firms, corporations, aysodadons, of and from any and all causes of acdon, suitu, judgments, claims and demands of whatsoever kind, iri Iaw or in equity, known and unknown, which I/we now have or may hereafter have, and/or which the minor AVAGROLLER now has or may hereafter have, i |ly the claimed legal liability of releasee(s which liability releasee(s) expressly d from or by reason of any and all bodily or personal injury and or property damage known and unknown, foreseen and unforeseen which heretofore has/have been or which hereafter may be sustained by melus or the minor aforementioned arising out of the accident on or about AUGUST 21 2012 (Year) a/ornoar NOBLEBOULEVARD.CARL|SLE.PA .in�he[ountyof CUK4BERLAND in the State of PENNSYLVANIA , in which the minor aforemeritioned sustained personal injuries and/or property damage. I/We agree that the consideration set forth is specifically applicable to and paid to ma/us with respect to any and all damage to any property, either real or personal, of mine/ours or the minor aforementioned, and with respect to any and all personal or bodily injury of mine/ours or the minor aforementioned, whether presently known or unknown, foreseen or unforeseen or which may subsequently develop and the consequences thereof, all as arising from the aforementioned accident. I/We further agree that the consideration set forth above is specifically applicable to and paid to s with respect to any right of contribution that //me or the minor aforementioned may have against the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns relative to claims of others that may be brought against me/us or the minor aforementioned by reason of said accident. |/Wo further agree that the consideration set forth above is specifically applicable to agreement that |/we or the minor aforementioned will not join nor attempt to join the releasee(s), his/her/their/its heirs, executors, adminiu\rators, insuraro, successors and assigns in any capacity, in any action that may be brought against me/us or the minor aforementioned arising out of said accident. In consideration of the aforesaid payment, |/we for myself/ourselves and my/our hnirs, rnpresen\odvns, executors, administrators, successors, and assigns do hereby: (1) agree to indemnify and hold forever harmless the releasee(s) and his/her/its/their/representatives, administrators, or assigns, against loss from any and all further c|aims, demands or actions that may hereafter be made at any time or brought against the releasee(s) by me/us or the minor aforementioned, or by anyone in our behalf for the purpose of enforcing a further claim, for which this release is given; (2) warrant that //we have received no money or other valuable consideration from any other person or persons by reason of any causes of action, suits, covenants, ngroaments, judgments, claims and demands of whatsoever kind, which I/we now have or may hereafter have, for injuries to person or property arising out of the aforementioned accident or for the other matters for which this release is Intending to � legally bound thereby, WITNESS my/our hand(s) and seal(s) this day of (Year) NOTICE: 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 the person to criminal and civil penalties. WITNESSES: C-41M-PA (R) 04/05 / (Seal) Father—Guardian `-` X Mother (Seal) ` ����m� Minor 0 CASH iNGENOING COINS • List Checks Singly SUBTOTAL IP LESS CAS n H RECEIVED TOTAL DEPOSIT $ 1:54? 505 2591:3000 246590 2 29116 •-• .ven,NR TAR AMMO SMUT 10 THE PROVISIONS OF THIUMTGREA COMMERCIAL CODE AND MEE APPUCASLE CCHAECTION AGREEMENT. K. Lee Derr, Esq. 1D# 71860 P.O. Box 841 Carlisle, PA 17013 (717)787-3118 1 Gabrielle Grolier and ) COURT OF COMMON PLEAS FOR 2 Ava Grolier (minor), ) CUMBERLAND County, Pennsylvania 3 Plaintiffs ) 4 ) 5 ) 6 vs ) DocketNo. 7 Charles Raffensburger and ) 8 11 L Stoneburger Plumbing, ) 9 Defendants. ) 10 ) 11 ) 12 13 14 PROOF OF SERVICE 15 16 17 COMMONWEALTH OF PENNSYLVANIA, COUNTY OF CUMBERLAND 18 19 I am a resident of the county of Cumberland, and am over 20 the age of eighteen years, and hereby certify that the within 21 document has been served as follows: 22 23 On March 24,2014, I served the within Petition For Leave To 24 Compromise Minor's Claim on the interested parties in this action by 25 placing a true copy thereof enclosed in a sealed envelope 26 deposited in the United States mail, first class, postage 27 prepaid at Harrisburg, PA, addressed as follows: 28 29 Ms. Deb Wallace 30 Erie Insurance 31 P. 0. Box 2013 32 4901 Louise Drive, Rossmoyne Business Center 33 Mechanicsburg, PA 17055-0710 34 35 36 Executed on March 24, 2014, at Carlisle, Pennsylvania 37 I hereby declare, under penalty of perjury, that the 38 foregoing is true and correct. 39 40 41 42 43 44 45 46 47 evin ee Derr K. Lee Derr, Esq. ID$ 71860 P.O. Box 841 Carlisle, PA 17013 (717)787 -3118 1 Gabrielle Grolier and 2 Ava Grolier (minor), 3 Plaintiffs ) 4 ) 5 ) COURT OF COMMON PLEAS FOR ) CUMBERLAND County, Pennsylvania 6 vs ) DocketNo. x`737 eumi 7 Charles Raffensburger and ) 8 H L Stoneburger Plumbing, ) 9 Defendants. ) 10 ) 11 ) 12 13 14 15 16 17 cr.0 18 AND NOW, this / day of , 2014, on consideration of 19 the foregoing petition, it is ORDERED that the sett l» ent in compromise of this action for the 20 gross sum of $6,000.00 is approved. Distribution is directed as follows: 21 22 23 To petitioner, as parent and natural guardians 9if minor- plaintiff, and to be placed in the 24 insured savings account in the minor's name at Wells far p , account number 300042 Yb 5.10 25 aa , and not to be withdrawn until minor plainti (reaches majority or order of a court 26 of competent jurisdiction, the sum of $6,000.00. ORDER (Proposed) 27 28 29 30 31 32 33 34 35 36 co 'es !1.LEL, PI 444_ kee—lea& By the Court: V C)