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HomeMy WebLinkAbout05-3316 II IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Norman H, Shelly, Jr., Plaintiff NO ()~ -~J/b (!;uit&'""l v, CIVIL ACTION - LAW Highmark Blue Shield, Defendant NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint of for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 'I I' IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Norman H. Shelly, Jr., Plaintiff v. NO O~- 33/~ e'"uL(~~ CIVIL ACTION - LAW Highmark Blue Shield, Defendant COMPLAINT 1. The Plaintiff, Norman H, Shelly, Jr., is an adult individual residing at 288 Dorsey Lane, Dillsburg, York County, Pennsylvania, 17019. 2, The Defendant, Highmark Blue Shield, is a business entity licensed to do business in the Commonwealth of Pennsylvania with the place of business located at Center Street, Camp Hill, Cumberland County, Pennsylvania. 3. On December 1, 1997 the Plaintiff was involved in an automobile accident and suffered serious injuries including injuries to his head, jaw and teeth. 4. There was a policy of insurance in effect at the time of loss with Highmark Blue Shield or it's prior entity. The contract provided for payment of loss for dental serves rendered by a physician or dentist which were required as a result of accidental injury to the jaws, sound natural teeth, mouth or face. 5. As a result of the loss the Plaintiff, Norman H. Shelly, Jr., has incurred expenses to correct the damages caused by the loss. As a result of the accident the Plaintiff did seek medical attention and was advised that he should wait at least a year or longer before the situation could be adequately evaluated and a proper course of medical action be determined. 6. On or about March 10, 1999 the Plaintiff did retain the services of Dr. Heidi L. Myshin of Myshin Prosthodontics to evalute his condition. Mr. Myshin recommended significant dental surgery and agreed to contact the Defendant insurance company to determine what insurance coverage was, in fact, available to cover the costs of repairs and replacements. II I 7, Dr. Myshin was advised by the Defendant that "no coverage for prosthetic dental services" was provided in the policy and consequently no reimbursements would be made, 8. This information was false, misleading and negligently provided to the medical provider thus leading to a inability of the Plaintiff to move forward with the necessary medical surgery. 9. In approximately 2003, when Plaintiff's medical condition deteriorated to the point that he could no longer sit by and wait for a determination by the Defendant, the Plaintiff did move forward and have the surgery completed by several doctors and did pay, out- of-pocket, for the same. 10. At the same time, and before the surgery was completed, Plaintiff's present counsel did contact the Defendant and requested information as to his coverage. 11. On May 3, 2003 the Defendant's representative, Sharon Shingara, indicated that the surgery would be covered and that the Plaintiff should submit to a "predetermination" review by the physician. At the request of the Plaintiff his treating physicians did submit such predetermination review but again, unlawfully, negligently and maliciously the Defendant insurance company refused to agree to pay for these covered services. 12. As a result of the Defendant's refusal to pay for such services the Plaintiff did cause the surgery to move forward and did incur medical charges in excess of $12,000.00 including medical bills for services rendered from the date of the accident through the surgery in 2003 for which the plaintiff has paid. 13, Despite repeated demand, including significant documentation provided to the Defendant insurance company, the Plaintiff has not been reimbursed for his out-of- pocket medical expenses in excess of $12,000.00 which sum the Defendant insurance company is obligated to repay to the Plaintiff. II COUNT I Bad Faith 14. Paragraphs 1 through 13 are incorporated herein and references made thereto. 15. Defendant, Highmark Blue Shield wrongfully refused to pay for this loss in accordance with the terms of the policy issued to the Plaintiff. 16. Defendant, Highmark Blue Shield, has frivolously and with no proper foundation for its actions has refused to pay all applicable benefit proceeds under its policy of insurance in accordance with the terms of the policy. 17. The bad faith conduct of Defendant Highmark Blue Shield gives rise to a cause of action pursuant to 42 PA.C.S.A.~8371 et. seq. 18. The Defendant, Highmark Blue Shield, failed to promptly and completely investigate all claims arising under the aforementioned contract of insurance, by reason of the aforesaid incident. 19. The Defendant, Highmark Blue Shield, did not act in good faith to effectuate prompt, fair and equitable resolution of claims, knowing that liability was clear and coverage applies and, as a result, the Plaintiff has been forced to incur the expenses mentioned above to protect his interest. 20. The Defendant, Highmark Blue Shield, failed to promptly provide a factually sound explanation for the basis of denial in the insurance policy in relation to the facts or applicable law for denial of the claim, 21. The Defendant, Highmark Blue Shield, has willfully, maliciously and/or recklessly withheld benefits from the Plaintiff, due to its failure to investigate the claim thoroughly which constitutes a breach of implied covenant. 22. The Defendant, Highmark Blue Shield, in bad faith, has denied payment on behalf of its insured without a sound legal basis for its denial and in not fully inquiring into the basis which might support the insured's claim of coverage. 23. Defendant, Highmark Blue Shield, has deliberately acted in conscience disregard and with indifference to the rights of its insured. 24. The Plaintiff, Norman H. Shelly, Jr., thereby requests all remedial relief as provided in 42 PA.C.S.A.~8371 in payment in full of all past and future reasonable and II necessary expenses arising from the loss including reasonable attorney's fees as I: determined by the court. I , WHEREFORE, for all of the above reasons, Plaintiff, Norman H. Shelly, Jr., requests judgment in his favor and against Defendant, Highmark Blue Shield in an amount in excess of that requiring compulsory arbitration. A trial in the Court of Common Pleas is therefore demanded. COUNT II Breach of Contract 25. Paragraphs 1 through 24 are incorporated herein and references made hereto. 26. The Defendant, Highmark Blue Shield, impliedly and/or expressly warranted that it would, in good faith, provide insurance coverage to Plaintiff, Norman H. Shelly, Jr., in accordance with the contract and abide by the terms of said contract. 27. As a result of its breach as identified above, the Defendant Highmark Blue Shield, did breach its contract and its warranty which breach resulted in a loss to the Plaintiff as outlined in more detail above. WHEREFORE, for all of the above reasons, the Plaintiff Norman H. Shelly, Jr., requests judgment in his favor and against the Defendant Highmark Blue Shield in an amount in excess of compulsory arbitration. A trial in the Court of Common Pleas is therefore demanded. Respectfully Submitted, TURO LAW OFFICES ~~, Da e Ron Turo, Esquire 28 South Pitt Street Carlisle, PA 17013 (717) 245-9688 Attorney for Plaintiff VERIFICATION I verify that the statements made in the foregoing Complaint are true and correct. understand that false statements herein are made subject to the penalties of 18 Pa.C,S. 94904 relating to unsworn falsification to authorities. r;, 113/0S- Date' I!ptv~ c/f11{f ~ /'.Torman H. Shelly, Jr. ?'V ~ f' U') --< "Cl ~ ~ ""6g. ~ .~ ~ B cs-v r- ~ () c ~;;:- lJr.y; S"~ t;; i0jc- .-/ -.~ c--'-,," ...,,--'_.' ~:E.~:, ...::~: =2 ...., ~ ~ '- .... c: :J: F1 ~ ~.~8 -0 :::;:!." - ) :z i:) ::d 70 _ (3m ;-4 N 55 -< SHERIFF'S RETURN - REGULAR CASE NO: 2005-03316 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHELLY NORMAN H JR VS HIGHMARK BLUE SHIELD KENNETH GOSSERT , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon HIGHMARK BLUE SHIELD the DEFENDANT , at 1538:00 HOURS, on the 6th day of July 2005 at 1800 CENTER STREET CAMP HILL, PA 17011 by handing to SALLY MCCOY, PARALEGAL, ADULT IN CHARGE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Postage Surcharge So Answers: 18.00 12.00 .37 10.00 .00 40.37 -~~./ ~ 1'"' ~z'~?::'r~~f~ R. Thomas Kline 07/07/2005 RON TURO Sworn and Subscribed to before By: "- me this /,2- day of (~').:~ th-f6. :;;, rothonotary , IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Norman H, Shelly, Jr., Plaintiff NO 0~5-3316 CIVIL TERM v, CIVIL ACTION - LAW Highmark Blue Shield, Defendant PRAECIPE TO THE PROTHONOTARY: Please settle, withdraw and discontinue the above-captioned action on behalf of the Plaintiff, Norman H. Shelly, Jr. Respectfullly Submitted TUR W OFFICES 7)7105 Date /( Ron Turo, Esquire 28 South Pitt Street Carlisle, PA 17013 (717) 245-9688 Attorney for Plaintiff <0- 'f;~ -tj /, r"t".,.\ I"':;,", ~ '3> ~ G'" ~~:~ \~2 t-~~~ Y:z :i Q, ~~ -:.bel '.'""It- (~}4, ~\.: --<I, '-2(5 "'" 'Zi'1' ::t:- <.1 ~ ::<: ~, .- ...> .- .' -