HomeMy WebLinkAbout09-02-14 IN RE: MARTHA JEAN MCCURDY : IN THE COURT OF COMMON PLEAS
an Alleged Incapacitated Person : OF CUMBERLAND COUNTY,
: PENNSYLVANIA
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PETITION FOR APPOINTMENT OF A PLENARY GUt�R�T`t�N � :.� �
OF THE PERSON AND ESTATE OF AN ALLEGED ;; c� rn
INCAPACITATED PERSON PURSUANT TO 20 PA. C.S. § �51� et s�. <n �
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NOW COMES Petitioner, Robert McCurdy, by and through his attorneys, the 3
law firm of Saidis, Sullivan & Rogers, and files the within Petition for Appointment
of a Plenary Guardian of the Person and Estate of an Alleged Incapacitated Person,
Martha Jean McCurdy, and in support thereof, avers the following:
l. Martha Jean McCurdy ("Mrs. McCurdy") is an alleged incapacitated
person whose legal residence is 11 W. Dulles Drive, Camp Hill, PA 17011.
2. Mrs. McCurdy's date of birth is March 6, 1930, and she is 84 years of age.
3. Petitioner, Robert McCurdy ("Petitioner"), is Mrs. McCurdy's husband.
4. Petitioner married Mrs. McCurdy on December 31, 1960. See Ex. A,
Marriage license from Oakland County, Michigan.
5. Petitioner resides with Mrs. McCurdy at 11 W. Dulles Drive, Camp Hill,
PA 17011, where he serves as her primary caregiver.
� 6. Pursuant to 20 Pa. C.S. § 2101 et se�c ., Petitioner, if his is the surviving
spouse, is Mrs. McCurdy's primary intestate heir.
7. Anne Markel, Mrs. McCurdy's daughter, whose legal residence is 292
Edinburgh Road, York, PA 17406, is also an intestate heir under 20 Pa. C.S. § 2101
et se�c .
8. Mrs. McCurdy was not and currently is not a member of the Armed
Services of the United States.
9. This court has jurisdiction under 20 Pa. C.S. § 5512(a) because Mrs.
McCurdy is a resident of Cumberland County.
�
10. To Petitioner's knowledge and belief, no other court has assumed
jurisdiction in any proceeding to appoint a guardian or to determine whether Mrs.
McCurdy is incapacitated.
11. To Petitioner's knowledge and belief, Mrs. McCurdy does not have a
guardian, trustee or power of attorney.
12. Mrs. McCurdy's primary care physician is:
Roger B. Gustavson, M.D.
890 Poplar Church Road
Suite 508
Camp Hill, PA 17011
13. On August 22, 2014, Dr. Gustavson, M.D. answered written deposition
questions regarding Mrs. McCurdy's mental, emotional and physical condition. See
Ex. B, Written Deposition of Roger H. Gustavson, M.D., Physician Qualified to
Render Opinion On Incapacitation of Marth Jean McCurdy.
14. It is the medical opinion of Dr. Gustavson that Mrs. McCurdy would be
harmed by in-person attendance at a hearing to determine her capacity because she
suffers from moderate to severe dementia that causes constant confusion and
disorientation.
15. Dr. Gustavson diagnosed Mrs. McCurdy's primary physical limitation as
moderate arthritis. Dr. Gustavson noted that Mrs. McCurdy can, at times, perform
some basic activities of daily living such as bathing, dressing and using the
restroom. Dr. Gustavson further stated that her moderate to severe dementia
leaves her unable to perform the essential requirements for her physical health and
safety.
16. Dr. Gustavson stated that Mrs. McCurdy began to manifest symptoms of
dementia in 2011. Dr. Gustavson opined that Mrs. McCurdy's moderate to severe
dementia causes the following limitations:
A. Mrs. McCurdy can not recall her own name or remember that she is
married;
B. Mrs. McCurdy, at times, will believe that there are people in the
room who are not present;
C. Mrs. McCurdy outwardly appears to be very pleasant, but is
actually very confused are disoriented.
- 2 -
D. Mrs. McCurdy can not manage her own finances.
E. Mrs. McCurdy can not meet the essential requirements for her own
health and safety.
F. Mrs. McCurdy is susceptible to undue influence by unscrupulous
individuals.
G. Mrs. McCurdy's condition will not improve and will continue to
deteriorate.
17. Mrs. McCurdy's lack of legal capacity eliminates execution of a power of
attorney as a viable less restrictive alternative to the appointment of a plenary
guardian.
18. Mrs. McCurdy is the sole owner of one asset, a Knights of Columbus
retirement annuity. Mrs. McCurdy jointly owns a checking account and her home
with the Petitioner. See Ex. C.
19. Mrs. McCurdy has a long term care policy with Penn Treaty and cannot
access its benefits without the appointment of a guardian. See Ex. D.
20. The severity of Mrs. McCurdy's cognitive and mental impairments and
the lack of a viable, less restrictive alternative necessitates the appointment of a
plenary guardian to manage and handle all aspects of her estate, including, but not
limited to: cash management, checks, personal property, real property, insurance,
government entitlement, taxes, execution of documents, entry into contracts,
payment of reasonable compensation for services provided and claims for benefits
due under long term care insurance policies.
21. The severity of Mrs. McCurdy's cognitive and mental impairments and
the lack of a viable, less restrictive alternative necessitates the appointment of a
plenary guardian to manage and handle all aspects of her person including but not
limited to: living arrangements, medical and psychiatric care, administration of
medication, employment and discharge of physicians and other health care
professionals, and other medical decisions as may be required.
- 3 -
WHEREFORE, Petitioner respectfully requests that the Court, pursuant to
20 Pa. C.S. § 5512.1, issue a Citation directed to Mrs. McCurdy, with notice to her
next of kin and to such other persons as the Court directs, to show cause why Mrs.
McCurdy should not be adjudged to be an incapacitated person and Petitioner be
appointed plenary guardian of her estate and person.
Respectfully submitted,
SAIDIS, SULLIVAN & ROGERS
DATE: Au ust 27, 2014 By: '�'N
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Anna Borro Hays, Esq ire
PA Identification No. 70375
635 North 12t'' Street, Suite 400
Lemoyne, PA 17043
717-612-5800
VERIFICATION
The undersigned, Robert McCurdy, hereby verifies and states that the facts set
forth in the foregoing Petition are true and correct to the best of his knowledge,
information and belie£ Furthermore, the undersigned understands that false
statements are made subject to the penalties of 18 Pa. C.S.A. § 4904 relating to
unsworn verification to authorities.
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Dated: , 2014 �
ROBERT McCURDY
���r�ttge �.icer��e
State File No.
��'�-� COUNTY, MICHlG�4N 2�2�$
Local File No.
To any person legally authorized to solemnize marriage in the State of Michigan,
- �reetit�g:
�Aarriage must be solemnized within 30 days of dc��e of issue in fbe Sfafe ot
Michigan betwe�n
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Full aame of male Full naine of female
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Age at last birthday . Color Age at last birthday Color
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Residence No. Street Residence No. Street
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City Zone No. State City Zone No. State
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Birthplace—c,ity and state Birthplace—city and state
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Occupation Occupation
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Number of tunes previously married : Number of times previously ma..ied
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w Mothcr's maidrn aame Mother's maidrn namc
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� parent's or guardian's consent, in case she has not aYtained the age of eighteen years, has been fi2ed in my office. An
affidavit has-b led in this office, as provided by Public Act No. 128, Laws of 1887; as smended, by which it appears
othat sai I' arue. _
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y �i1 witness whereof, I have signed and sealed these presents, this
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�� day of �� , A. D. 19 �
���`��s �; . ;'�D e��
County erk
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� iage license VOI 30 days after da�Fe of issue.
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Between Mr. ���� ��� ����'`�� _ and ItR ����;�'�``� '�"��� ��
I hereby eertify that; in accordance with the above license, the persons herein mentioned were joined in
mamage by me, at PontiAC , county of ������ , MICHIGAN,
on the day of A. D. 19 in the presence of
Roy Boatstead o�Pontiac) ::Orion R?Iich �,d
Full name Residence—city an3 state
I��ar3r ponahue of Pontiac
� � . Full�name � `%��%)� ��j� .Residence—city and st�,te
as witnesses. `�,�,� �a8't02'
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ST. VI�CEhvT DEP�.�'Ps�w2Ti�Ytddres�.
1�! �GU�ii FF:kK� STREET X�, �tll�va�'�f C���ctt.f� �r:t'i''
THIS DUPLICATE must be delivered by the person "soleef►nizieg�Hi�.qn! � ��`
marriage to one of the parties joined in marriage. 7��u• ��rke Sfire�t
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WRITTEN DEPOSITION OF ROGER B. GUSTAVSON, M.D.
PHYSICIAN QUALIFIED TO RENDER OPINION ON
INCAPACITATION OF MARTHA JEAN MCCURDY
l. Please state your name and professional addiess.
Roger B. Gustavson, M.D.
890 Poplar Church Road, Suite 508
Camp Hill, PA 17011
Phone: 717-761-3875
Fax: 717-761-7893
2. Please desciibe your education, training and expeiience. You may also
attach a copy of your curriculu�n vita-e.
See attached curriculum uitae.
3. Please describe the natuie and length of your professional ielationship
with Maitha Jean McCurdy. In paiticular, please desciibe when Maitha Jean
McCurdy became your patient and how often you have eithei examined or tieated
hei since she became youi patient.
Martha Jean McCurdy has been a patient since October 1977. I
see her for periodic exams as n�eded, approximately once or
twice per year.
4. Please evaluate and piovide your opinion on the nature, extent and
severity of the alleged incapacity and disability of Martha Jean McCuidy including
hei cuiient mental, emotional and physical condition, adaptive behavior and social
skills.
a. Mental and Emotional Condition:
Beginning in November 2011 she began showing signs of
confusion and disassociation.
b. Physical Condition:
Except for moderate arthritis pain, her physical
condition has been quite good.
c. Adaptive Behavior:
Increasing confusion, forgetting that she is married and
at times unable to recall even her own name. At times
she imagines that there are other people in the room.
d. Social Skills:
Severely impaired. She appears very pleasant and social,
but on close inspection is found to be very confused and
disassociated.
5. Based upon youi education, tiaining, experience and contacts with
Martha Jean McCuidy, do you have an opinion, to a reasonable degree of inedical
ceitainty, whether she is impaired in her ability to effectively receive aiid evaluate
information and to make and communicate decisions in any way? If you conclude
that Martha Jean McCuidy is impaiied, please explain your opinion.
Martha Jean McCurdy is severely impaired in her ability to
carry on any activities beyond simple activities of dressing and
bathing and toileting and she sometimes needs help with those
activities. Her higher cognitive function is severely impaired.
6. If you opine that Martha Jean McCurdy is impaired in her ability to
effectively ieceive and evaluate information and to make and communicate
decisions in any way, does such impairment cause her to be either partially or
totally unable to manage her financial resources?
Partially unable to manage her own finances
X Totally unable to manage her own finances
Please explain hei opinion of either paitial oi total impaiiment.
She is significantly confused essentially all the time.
7. If you opine that Martha Jean McCurdy is impaiied in hei ability to
effectively receive and evaluate infoimation and make and communicate decisions
in any way, does such impairment iender hei eithei partially or totally unable to
meet the essential iequiiements for hei physical health and safety.
X Partially unable to meet essential iequiiements for her
physical health and safety
Totally unable to meet essential iequirements for her
physical health and safety
Please explain youi opinion of either partial or total impaiiment.
Once again, due to her moderately severe dementia, she is
unable to meet the essential requirements for her own physical
health and safety.
8. Is the condition of Martha Jean McCuidy such that because of hei
condition she would be susceptible to undue influence by unscrupulous or desigiling
persons?
There is no question that she would be susceptible.
9. If you answer question eight in the affirmative, what services or
assistance would you iecommend as necessary for appropriate management of
Maitha Jean l�2cCuidy's finances?
The patient's husband or a guardian appointed by the Agency
of Aging or the Commonwealth.
10. What services or assistance would you recommend as necessaiy to
meet Martha Jean McCurdy's health and safety needs?
The patient's husband or visiting nurse/home health seivices.
11. Aie the seivices oi assistance recommended the least restrictive
alternatives?
Yes.
12. In your opinion, can Martha Jean McCurdy evaluate, communicate
and make decisions regarding her health treatment, safety and financial resouices
in important matters without a guardian?
No.
13. Please explain why an alternative that is less iestrictive than a
guaidianship is not appropriate?
The patient has a cognitive impairment caused by moderate to
severe dementia.
14. Based upon your education, tiaining, experience and familiarity with
Mrs. McCuidy, what is your opinion as to the likelihood that the degree of
incapacitation will significantly change?
There is no chance that her condition will improve; hopefully,
with the medications prescribed, her decline will be slowed.
15. Would the physical or mental condition of Martha Jean McCurdy be
haimed by her presence in open court?
Ye s.
NOTE: Pennsylvania law, 20 Pa. C.S. § 5511(a)(1), requires that the alleged
incapacitated person be present at the hearing unless a physician or
licensed psychologist provides by deposition, testimony or sworn
statement, an opinion that the patient's physical or mental condition
would be harmed by his or her presence in court.
VERIFICATION
I, ROGER B. GUSTAVSON, M.D., veiifv that the statements made in the
foregoing deposition are true and correct to the best of my knowledge, information
and belief. I undei stand that the statements herein are subject to the penalties of
18 Pa.C.S. §4904 relating to unsworn falsification to authorities.
����� _ �. �- a-�
�---
RO B. C'�USTAVSON, M.D.
D�TED: � 2z ��
,����.���-,�� ,.�,��.� �f���.,�. � t�� . ,._
ROGER B. GUSTAVSON, M.D.
OFFICE ADDRESS: 890 Poplar Church Road, Suite 508
Camp Hill,PA 17011
Phone: (717)761-3875 FAX: (717) 761-7893
EMPLOYMENT:
1974-present: Susquehanna Internal Medicine Associates,P.C.
890 Poplar Church Road Suite 508
Camp Hill, PA 17011
PROFESSIONAL DATA:
Licensure: Pennsylvania License Number MD 012082E
Hospital Affiliations: Holy Spirit Hospital, Camp Hill,PA—,Active Staff
Harrisburg Hospital,Harrisburg,PA—Active Staff
Diplomate: The American Board of Internal Medicine 1974
Appointments: Director,Division of Medicine,Holy Spirit Hospital 2003 -present
President,Holy Spirit Hospital Medical Staff- 2000
Vice President,Holy Spirit Hospital Medical Staff- 1999
Secretary/Treasurer,Holy Spirit Hospital Medical Staff- 1998
Board Member,Holy Spirit Hospital 1998-2000
Professional Associations: Pennsylvania Medical Society
Dauphin County Medical Society
American Society of Internal Medicine
Society of Diplomates of Harrisburg
EDUCATION:
1972-1974 Internal Medicine Residency—Chief Resident 1974
Harrisburg Hospital
111 South Front Street
Harrisburg,PA 17101-2099
1970-1972 Active Duty United States Navy
Lieutenant Commander Medical Corps,USNR
Honorable Discharge,June 1972
1969-1970 Internal Medicine Internship
Harrisburg Hospital
111 South Front Street
Harrisburg,PA 17101-2099
1965-1969 Temple University School of Medicine
Philadelphia,PA
M.D. ganted 5/26/69
1961-1965 Colgate University
Hamilton,NY
B.A. granted 5/28/65
�C�F�
KNIGHTS OF COLUMBUS
MAKING A DIFFERENCE FOR LIFE
August 6,2014
Martha Jean McCurdy
11 Dulles Dr W
Camp Hill, PA 17011-1111
Subject: Policy�—Value Letter as of August 6th, 2014
Dear Mrs.McCurdy,
The accumulated value on the above is$9,923.46. if you were to surrender the policy,the value would
then be$9,689.84.
If you have further questions, please direct them to our customer service area on their toll free line
1-800-380-9995.
Very truly yours,
Annuity Processing
1 COLUMBUS PLAZA • NE1N HAVEN, CONNECTICUT 06510-3326 • TEL. 203-752-4000 • W1NW.KOFC.ORG
Knights of Columbus � � �
� � INSURANCE
Making a difference for life.
Contract nusnber : � For inquiries, please contact your
Issue Date : August 4, 2009 General Agent at
Tax Status : TRADITIONAL IRA (717) 737-7606
General Agent:
MARTHA JEAN MCCURDY JOHN J MITCHELL
11 DULLES DR W
CAMP HILL PA 17011-1111 Customer Service (B00) 380-9995
Monday-Friday B:OOa.m. to 7:30p.m. ET
ANNUITY ANNUAL STATEMENT FOR PERIOD ENDING August 4, 2014
This statement describes the current status of your contract and summarizes the
�ctit•ity fcar tha- peri-o�? sh�wn belo�*.
CONTR.ACT SUMMARY
08/04/2013 Accumulation Value 10,244.92 Surrender Value 9,974.15
Premiums +0.00
Withdrawals -617.63
Interest Credited +294.54
OS/04/2014 Accumulation Value 9,921.83 Surrender Value 9,667.28
The interest amount shown on this statement was calculated using the rate or rates
in effect during the statement period. The current rate on premiums received during
the calendar quarter in which this statement was printed is 3.00 `•k. Funds previously
credited ma earn a rate that is higher or lower than the current rate. Your
contract has a lifetime minimum guaranteed interest rate of 3.00 �.
Monthly activity for period ending August 4, 2014
Calendar Month Premiums Withdrawals
August 2013 0.00 0.00
September 0.00 0.00
October 0.00 0.00
November 0.00 617.63
December 0.00 0.00
January 0.00 0.00
February 0.00 0.00
March 0.00 0.00
April 0.00 0.00
May 0.00 0.00
June 0.00 0.00
July 0.00 0.00
August 2014 0.00 0.00
Total 0.00 617.63
Council: 10685 Printed OB/04/14 0
E��O Metro Bank
3801 Paxton Street
BA N K Harrisburg PA 17111-1418
1-886-937-0004
mymetrobank.com
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>t14311 4328362 �01 092140
ROBERT J MCCURDY
OR MARTHA J MCCURDY
11 W DULLES DRIVE
CAMP HILL PA 17011
1Ne're here 7 days a week,24 hours a day at 1-888-937-0004.
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07/09/14 � CHASE AUTOPAY � � $67.95 $16,601.52
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Total Returned Item Fees Year to Date $0.00
For your convenience,a summary of overdraft and returnad item fees appears on your monthly statement. Ptease note that the overdraft fee
summary includes non-sufficient funds fees,uncollected funds fees and unavailable funds fees. The summary does not reflect refunded or waived o
items credited to your account. $
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statements with check images can be requested for$3 each.eStatements include check images, are available at no 0
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92140 ROLL W/11
tel 800.362.0700
PENN TREATY� www.penntreay.com
July 24, 2014
ROBERT MCCURDY
11 W DULLES DR
CAMP HILL PA 17011
RE: Policy#:�
Policyholder: Martha Jean McCurdy
Dear Mr. McCurdy:
Thank you for your letter regarding the above-referenced policy. We are taking this opportunity to address your
correspondence received July 10, 2014. We welcome every occasion to serve our policyholders and hope that you
wili find the following information helpful.
We would like to respond to your comments expressing concern with our services during your wife's claim. Our
records indicate on June 2, 2014 we received notification that Mrs. McCurdy required Home Health Care services
under her Alternative Pian of Care benefit. Our Intake clerk was able to speak with you by phone and you advised
care would be provided by Visiting Angels. At that time, you were advised of the claims forms that were required
to consider her claim and on June 4, 2014, we sent out a claim acknowledgement letter to Mrs. McCurdy with an
Alternative Plan of Care Home Care form that includes two sides; a Policyholder Proposal for home care and
Physician Recommendation for home care:We also ordered an in-home assessment from an independent vendor.
We received the face-to-face assessment completed by an independent vendor on June 16, 2014, and the
Physician's Recommendation for Home Care and the Policyholder Proposal for Home Care on June 20, 2014. It
was determined that we required an Evaluation for Cognitive impairment and this was requested from Dr.
Gusiavson on�uly 2, 2014.
A second request letter was sent to Mrs. McCurdy for billing and care notes on July 2, 2014, as our claims
examiner was not sure if care had began at that point. We apologize for any inconvenience the wording in the
second request letter may have caused you as it indicated we would discontinue active processing of her claim if
we did not receive this information by July 15, 2014.This is a standard form letter which the claims department
uses in order to keep all claims within state regulations and protocols.
The Evaluation of Cognitive Impairment was received on July 9, 2014 and our claims examiner determined Mrs.
McCurdy was eligible for benefits under her policy.Our nurse case manager contacted you on July 10, 2014 to
review Mrs. McCurdy's care needs and recommend an appropriate Plan of Care (POC.) At that point,the nurse
Penn Treaty Network America Insurance Company (In Rehabilitation)
(Penn Treaty Network Americo Life Insurance Compony in Californio)
American Network Insurance Company (In Rehabilitation)
3440 Lehigh Street :: Allentown, PA 18103
recommended 10 hours per day, 1 day per week at your request.The Alternative Plan of Care letter was sent on
July 14, 2014 and was received back in our office signed on July 22, 2014.
Once care begins,we wiil require Itemized Billing and Caregivers Daily Care Notes or Activity Logs from the
agency providing the care services in order to keep Mrs. McCurdy's claim open. If care is not provided on a regular
ba5is,the claim will be closed until biliing and carenotes are submitted.
We note that we do have authorization to discuss Mrs. McCurdy's claim with you based on the signed
�'uthorization from Mrs. McCurdy; however, please be aware that in order for you to make any decisions
r garding her policy, we would require a copy of your wife's financial or durable power of attorney or
uardianship document from the courts to evidence that you have such authority.The heaithcare power of
attorney that was sent to us would allow you to make healthcare decisions for your wife, but the decisions made
under this policy are financial in nature which is why the other document would be required.
We strive to provide excellent customer service to all of our policyholders and if there is anything I can do to assist
you, please contact me directly at(800) 362-0700, ext. 6119.
Sincerely,
1���,a,n,d.`.c'` I l�
Brandi Monfre, Review Specialist
Customer Dispute Resolution �