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Home My WebLink About12-28-05 Gerard C. Kramer I.D. No. 44715 SCHMIDT, RONCA & KRAMER, P.C. 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Petitioner C) o ~,:l ...., c;.~ ~;:--) "" r:-, "~'-l c) ="'"7 . ;-T'J , , (,~J .' ':, ) ....:2 "-[ h,) OJ (C':') r'o-J ; ~ ~J -,., GJ CD In re: ESTATE OF LOUISE DONMOYER, COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Deceased : No. 21-05-0400 BY Gary Donmoyer and Debra Donmoyer McClain, Executors, : ORPHAN'S COURT DIVISION Petitioners PETITION FOR APPROVAL OF UNDERINSURED MOTORIST LEVEL TWO SETTLEMENT AND NOW comes the Petitioners, Gary Donmoyer and Debra Donmoyer McClain, as Executors of the Estate of Louise Donmoyer, deceased, pursuant to 20 Pa.C.S.A. S 3323 approval of a Compromise Settlement in the above matter and further sets forth as follows: 1. The Petitioners, Gary Donmoyer and Debra Donmoyer McClain, are adult individuals, the children and beneficiaries of the Estate of their mother, Louise Donmoyer. 2. The Petitioner Gary Donmoyer and Debra Donmoyer McClain are Executors of the Decedent's Estate by virtue of Letters Testamentary which ; were granted to her by the Register of Wills of Cumberland County, on April 28, 2005 at File No. 21-05-0400. (See Exhibit "A" of Plaintiffs Petition for Approval of Settlement). 3. Ms. Louise Donmoyer was injured In a motor vehicle accident which occurred on October 30,2004. 4. A petition for approval of the third party settlement was filed on October 31, 2005. An order approving that settlement was signed by Judge Edgar B. Bayley on October 31,2005. 5. A petition for approval of first level of underinsured motorist settlement was filed on November 28,2005. An order approving that settlement was signed by Judge Edgar B. Bayley on December 1, 2005. 6. Plaintiffs are now seeking approval of the settlement of the second level of underinsured motorist coverage. 7. Ms. Louise Donmoyer was the passenger of a vehicle traveling south on Orrs Bridge Road in Hampden Township in Cumberland County. 8. Another vehicle driven by Marcia Reynolds, which was driving northbound on Orrs Bridge Road, crossed the center line of the road. 9. A head-on collusion occurred between the two vehicles. The driver of the vehicle in which Ms. Louise Donmoyer was a passenger was killed instantly. (See Exhibit "B" of Plaintiffs Petition for Approval of Settlement). 10. As a result of the accident, Ms. Donmoyer was hospitalized at Hershey Medical Center for multiple fractures. While hospitalized she developed complications. Her initial stay at Hershey Medical Center lasted 19 days before she was transferred to HealthSouth. 11. At HealthSouth it was determined that Ms. Louise Donmoyer had suffered from significant losses in her cognitive ability and that she was becoming depressed from the accident. 12. After experiencing respiratory distress Ms. Louise Donmoyer was transferred to Hershey Medical Center. 13. She was subsequently released to Select Long Term Acute Care. She returned to Holy Spirit Hospital for gastrointestinal bleeding after she vomited almost a cup of bright red blood on February 24, 2005. 14. After surgery in March 2005, Ms. Donmoyer was discharged to her home for home-care. 15. Ms. Louise Donmoyer passed away on April 22, 2005 from cardiac arrest at physical therapy. (See Exhibit "C" of Plaintiffs Petition for Approval of Settlement). 16. Executors retained Schmidt, Ronca and Kramer, P.C. to investigate and pursue a personal injury claim against Ms. Marcia Reynolds, on a contingency fee agreement permitting 25% attorney's fee and agreeing to reimburse Schmidt, Ronca & Kramer, P.C. all costs and expenses as incurred on the his behalf to make the claim. (See Exhibit "0" of Plaintiffs Petition for Approval of Settlement). 17. The claim against the third party liable for the accident was settled for $249,000.00 (See Exhibit "I" of Plaintiffs Petition for Approval of Underinsured Motorist Settlement). 18. The first level of underinsured motorist coverage is with Travelers Insurance and has been settled for $100,000.00. (See Travelers Insurance Release attached as Exhibit "A"j. 19. The second level of underinsured motorist coverage is with AllState. (See AllState Declaration attached as Exhibit "B"). 20. AllState has offered the policy limits of $100,000.00 for settlement. (See December 2,2005 letter from AllState attached as Exhibit "C"). 21. Petitioners consider the settlement amount of One Hundred Thousand Dollars ($100,000.00) to be fair and reasonable. (See Verifications attached as Exhibit "0"). 22. The Petitioners, Gary Donmoyer and Debra Donmoyer McClain are the only beneficiaries to the Estate. No minors are involved. 23. The Pennsylvania Department of Revenue has approved an apportionment of 50% to wrongful death and 50% to Survivor Action. (See PA Dept. of Revenue letter attached as Exhibit "E"). 24. Having retained the law firm of Schmidt, Ronca & Kramer, P.C. because of their expertise in these types of cases and signed a contingent fee allowing a 25% fee, Petitioners consider this to be reasonable for the work, expertise, and effort of the law firm. 25. To accomplish the Settlement, Schmidt Ronca and Kramer, P.C. incurred expenses including fees for filing resulting in a total cost of $15.00. 26. After the first petition $78,858.43 was paid to Medicare to satisfy the lien. However, medical providers have continued to send bills to Medicare and the Medicare lien was not completely satisfied. The remaining balance of the Medicare lien is $16.51. (See Medicare letter dated December 1, 2005 attached as Exhibit "F"). 27. The Petitioners requests that the following distribution be approved: Wrongful Death Action (50%) $ 100,000.00 $ 50,000.00 TOTAL SETTLEMENT Schmidt, Ronca & Kramer, PC Attorneys' Fees (25% of $50,000.00) $ 12,500.00 Schmidt, Ronca & Kramer, PC Attorneys' Costs $ 7.50 TOTAL PAYABLE in wrongful death action to Gary Donmoyer and Debra Donmoyer McClain $ 37,492.50 Survival Action (50%) $ 50,000.00 Schmidt, Ronca & Kramer, PC Attorneys' Fees (25% of $50,000.00) $ 12,500.00 Schmidt, Ronca & Kramer, PC Attorney Costs $ 7.50 $ 16.51 Medicare Lien TOTAL PAYABLE to estate in Survivor Action $ 37,475.99 28. Petitioners also request the Court grant permission to execute the Release attached hereto as Exhibit "G." WHEREFORE, the Petitioners requests that this Honorable Court enter the Order attached to this Petition approving the compromise settlement, directing the distribution of the proceeds as set forth herein, and authorizing him to sign a general release. Respectfully submitted, SCHMIDT, RONCA & KRAMER P.C. ------ By: Gerard C. Kramer, Esquire LD. # 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs UNDERJNSURED MOTORIST RELEASE KNOW ALL MEN BY THESE PRESENTS, that We, Debra Donmoyer McClain and Gary De~"is Donmoyer, as Executors of the Estate of Louise E. Donmoyer acknowledge receipt of the SLfIl of One Hundred Thousand and 00/100 Dollars ($100,000.00), and paid by Travelers Persona Security Insurance Company (Travelers) , in full settlement of all claims submitted to Travtlers Personal Security Insurance Company (Travelers), for Underinsured Motorist Benefits, a~erted against policy number 947535705 1011 for bodily injury, sickness, or disease, resulting and!o result from a certain accident which happened on the 30th day of October, 2004 on or near Qrrs Bridge Road, Hampden Township, PA for which we have claimed the owner, operator or person or organ ization responsible for the operation of an underinsured automobile to be liable. It is specifically understood and agreed upon by and between the parties that any Medicare I~n existing in connection with this claim shall be satisfied by Debra Donmoyer McClain and Gary Dennis Donmoyer from the proceeds of this settlement. Moreover, Debra Donmoyer McClain and Gary Dennis Donmoyer agree to indemnify and save harmless Travelers Personal Security Insurance Company (Travelers) on account of any such Medicare lien. IN WITNESS WHEREOF, We have hereunto set our hands and seals the /zt<-aay of ?LdtLU"~4L.___~ > in the year Two Thousand Five. Signed, seal and delivered in the presence of: WITNESS: G.~~Ii-""'l ,-,<",,"1.4~~/ ADDR SS:J D<( S+uk Sf- HOL[r"6,,, 'd/rf Olal 1 C <----------- :lJdY4L I. Ytf'I'Vf'M7JOu J1/c d tUtD Debra Donmoyer McClain (}.;/f///IUIIA.c<..Cl..1 fL -SlME-eF PENNSYLVANIA ~_.C1f /~J!/J""'A'-i"( /' .....({J C'J'14-1-'--t:'~{ ;fk ._-~--u.....,.-,....-..--._...;:_--...!_-_._..- / l Gary Dennis Donmoyer " COUNTY OF MD.-LeI'Iv. v- Sworn to and subscribed before me this }2.t'-- day of71l..<:.s;,.~f,.-,-.~ ,2005. ; ss . .. 'f;' . . z: V . ". '. (:' '....' " /ljeCCt_,..,..-- ( .,c__,..;:. ~{ Notary Public I COMMONWEALTt. OF PENNSYLVANIA Notarial Seal Dawnn E. Trostle, NotaJy Public City 01 Hanisburg. Dauphin County My Commission Expirns Aug. 25, 2009 Member. Pennsylval'lla ,t\ssoclatron of Notaries Ql)) Allstate. Vou.re in good hands. Allstate Insurance Company RENEWAL Auto Policy Declarations Summary NAMED INSURED(S) Louise E Donmoyer 1077-8 Lancaster Blv Mechanicsburg PA 17055-4492 YOUR ALLSTATE AGENT IS J Kelley & Son Inc (717) 737-6030 4930 Carlisle Pk 110 MechanicsbUrg PA 17055 YOUR BILL lists your payment options. POLICY NUMBER o 98 832788 04/11 POLICY PERIOD Oct. 11. 2004 to Apr. 11. 2005 at 12:01 a.m. standard time DRIVER(S) LISTED Louise DRIVER(S) EXCLUDED None VEHICLES COVERED 1. 9B Honda Accord VEHICLE ID NUMBER 1HGCG3251WA007000 LIENHOLDER None Total Premium Premium for 98 Honda Accord $327.50 $327.50 TOTAL ./ Your loral promlum refl.els. combin.d discount otll55. 73 Your Pollc, Effoclfr. 0.10 /s Del. II, 2004 IN ACCORDANCE WITH SECTION 172S Of THE MOTOR VEHIClE FINAJ<<:IAL RESPONSIBILITY lAW, THIS IS TO INFORM YOU THAT COlLISION DAMAGE TO A RENTAL VEHICLE WU IE COVERED IF: I) THE RENTAL VEHICLE IS A FOUR WHIR PRIVATE PASSENGER AlITOMOIILE OR A UTILITY AUTOMOBILE, AHlI 2) AT LEAST ONE PREMIUM FOR AUTO COLLISION COVERAGE APPEARS ON YOUR POLICY DEClARATIONS. COVERAGE WILL IE SUBJECT TO OEOUCTIILES AND TO POLICY TERMS AND CONDITIONS, INCLUDING ANY APPLICABLE ENDORSEMENTS. ~lliiliiii2Iiill~IIIIIIIIIIIIIIIIIIIIIII.I~111111 hll~frTlilGUlla~1 S~ptember'},2004 Page 1 PA01CRBD Allstate Insurance Company Policy Numbor : 0 98 832788 04/11 Policy Enocli.. oalo: Dol. 11, 2004 Your Ago.l: J Kollo, & So. 1.0 (717)737-6030 COVERAGE FOR VEHICLE # 1 1998 Honda Accord COVERAGE LIMITS DEDUCTiBlE PREMIUM Automobile Liability Insurance -- Limited Tort · Bodily Injury $100,000 each person Not Applicable $43.33 $300,000 each occurrence . Property Damage $50,000 each occurrence Not Applicable $62.01 Medical Expenses $5,000 each person Not Applicable $16.72 Uninsured Motorists Insurance $100,000 each person Not Applicable $19.62 Limited TortI Nonstacked Limits $300,000 each accident Underinsured Motorists Insurance $100,000 each person Not Applicable $17.23 Limited TortI Nonstacked Limits $300,000 each accident Auto Collision Insurance Actual Cash Value $500 $120.06 Auto Comprehensive Insurance Actual Cash Value $100 $48.53 Total Premium lor 98 Honda Accord $327.50 DISCOUNTS Your premium for this vehicle reftects the following discounts: Passive Restraint $7.16 55 and Retired Multiple Policy $18.55 Antilock 8rakes Premier Plus $72.67 Keep in mind that we offer a number of other discounts that may save you money. More infonnation can be found on the 'Your Savings and Rewards. page that precedes this Policy Declarations. $32.31 $25.04 RATING INFORMATION This vehicle is driven over 7,500 miles per year, for pleasure, retired adult age 73 Inl00000000lortaur SeplelNllrt.~ Page 2 PA010AllD Allstate Insurance Company Vour Agonl: J Kolley & Son Ine (717) 737-6030 ~AlIstate. You're In good hands. Pulley Numbo, : 0 98 832788 04111 Puliey Elled/.. Dill: Del. 11,2004 Your Policy Documents Your auto policy consists of this Policy Declarations and the documents listed below. Please keep these together - Pennsylvania Auto Insurance Policy form AU10623 - Pennsylvania Amendatory Endorsement form AU1 0681 IN WITNESS WHEREOF, AlIslal. has caused this policy to be signed by its Secretary and its President at Northbrook, Illinois, and if required by state law, this policy shall not be binding unless countersigned on the Policy Declarations by an authorized agent of AlIslal.. ~A"/~ /l,U,v.~ Secretary President, Personal Lines iillliiiieiimllllllllllllllllllilllllllllllllll tllllfllllbonasol s..pterrtl.r~.2OIl4 Page 3 'AnIORBD ~ HARRISBURG . >lll Allstate 6345 FLANK DRIVE, SUITE 1000 . sHARRISBURG PA 17112-2765 You're in good hands. ., z6S~ 1",111",1",111111""11",11",11,,11,11,,,1,1,,1,1,,1",11 GERARD C KRAMER ESQUIRE 209 STATE ST HARRISBURG PA 17101-1130 December 02, 2005 INSURED: LOUISE E DONMOYER DATE OF LOSS: October 30, 2004 CLAIM NUMBER: 1554999430 B27 Reference: Louise Donmoyer PHONE NUMBER: 800-726-8890 FAX NUMBER: 717-540-7540 OFFICE HOURS: Mon - Fri 8:00am - 5:30pm Dear Mr. Kramer: Please be advised that we are offering our policy limits of $ 100,000. Enclosed please fmd the proposed VIM release. Once this claim has been court approved we will be in a position to release the settlement draft. As always, thank you for your cooperation with this matter. Sincerely, fJim Slia.ffer Tim Shaffer 717-540-7555 Allstate Insurance Company GENIOO I 1554999430 B27 VERIFICATION I, the Petitioner, Debra Donmoyer McClain, an Executrix of the Estate of Louise Donmoyer, hereby verifY that the statements set forth herein are true and correct to the best of my knowledge, information and belief. I am satisfied that the offer of structured settlement, referred to in this Petition, for Ms. Donmoyer's injuries is just and reasonable and I am willing to accept that offer. I have reviewed the contents of the Petition for Approval of Underinsured Motorist Level Two Settlement and concur with all the facts and statements. I understand that intentional false statements herein are made subject to the penalties of 18 Pa. C.S. 134904 relating to unsworn falsification to authorities. Date: {:f.-nibs IQdv~ 1~C!YVmIL~ mccf~ Debra Donmoyer Motlain, as Executrix of the Estate of Louise Donmoyer VERIFICATION I, the Petitioner, Gary Donmoyer, an Executor of the Estate of Louise Donmoyer, hereby verify that the statements set forth herein are true and correct to the best of my knowledge, information and belief. I am satisfied that the offer of structured settlement, referred to in this Petition, for Ms. Donmoyer's injuries is just and reasonable and I am willing to accept that offer. I have reviewed the contents of the Petition for Approval of Underinsured Motorist Level Two Settlement and concur with all the facts and statements. I understand that intentional false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904 relating to unsworn falsification to authorities. Date: 1,),/.27/0 S ~ j)~~ Gary onmoyer, as E ecutor of the Estate of Louise Donmoyer Bureau of Individual Taxes PO Box 280601 Harrisburg, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE o -'h.J-:~. ,*V Telephone: 717-787-1794 Fax: 717-783-3467 Email: hmccJintoctO>state.oa.us December 19, 2005 Gerard C. Kramer, Esq. SRK Law 209 State St. Harrisburg, PA 17101 Re: Estate of Louise Donmoyer File Number: 2105-0400 Dear Mr. Kramer: The Department of Revenue has received a letter concerning the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the letter, the 74-year-old-decedent died as a result of complications from a motor vehicle accident. Decedent is survived by her two adult children. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 50,000 to the wrongful death claim and $ 50,000 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.SA 98302; 72 P.S. 999106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merrvman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death I survival action. Since~ely, ._jl '.A ((' t )-~t-. 'le y. ,1\./ \...,.,)(. \..." 1[( ( , Holly A. McClintock Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes ! :... c./Ws/ CENTEJIS&ME/JICA6E~MElJIG4H)Sl"RWtU I o MuruiL<tOmiHi MUTUAt OfOMA.HA I:-"SI)RA~CE COMPANY Medicare Division P.O. Box 1602. Omaha, NE681 01 402 351 3502 (For Attorney/Insurers tor Pos(.$ettlement) www.mutualmedicare.com A eMS Contracted Intermedia'Y December I, 2005 GERARD C. KRAMER ATTORNEY AT LAW 209 STATE ST. HARRISBURG,PA 17101 Re: LOUISE DONMOYER HIC No.: 18022240ID Date of Accident: 10/30/04 Dear MR. KRAMER: The attached letter is sent to you in accordance with regulations from the Centers for Medicare and Medicaid Services. This letter outlines your appeal rights in accordance with 45 CFR 30. 14. Medicare is in receipt of your check dated 11/14/05 in the amount of$58,978.37. However, I find that Medicare payment was made for a total of $58,994.88 see attached payment summary). The amount of repayment is insufficient to 'scharge the 0 'gation and the debt is not fully extinguished. Please send repayment in the amo t of$16.51, reg esenting the outstanding balance. If you have any questions, please feel free to contact me at the numbe Thank you for your courtesy and cooperation in this matter. Sincerely, '>n~ 3!low-r- Mary Brown Accounts Receivable Analyst Medicare Secondary Payer (402) 351-3201 Fax (402) 351-1401 Business Hours 7:00 a.m. - 4:30 p.m. Monday-Friday Central Time Enc. cc: ESTATE OF LOUISE E. DONMOYER 35111816.786 ALLSTATE INSURANCE COMPANY RECEIPT AND RELEASE UNDER UNDERINSURED MOTORIST INSURANCE -- Coverage SU SUBROGATION AGREEMENT CLAIM # 1554999430 B27 In consideration of the payment of One Hundred Thousand Dollars ($100,000.00) by Allstate Insurance Company, the receipt of which is hereby acknowledged, the undersigned hereby forever releases and discharges the Allstate Insurance Company from any and all liability and from and all contractual obligations whatsoever under the coverage designated above of Policy No. 098832788 issued to LOUISE E DONMOYER by the Allstate Insurance Company, and arising out of bodily injury, sustained by me due to an accident on or about the 30th day of October, 2004. The undersigned hereby assigns, transfers and sets over to the Allstate Insurance Company any and all claims or causes of action for which the undersigned now has, or may hereafter have, to recover against any person or persons as the result of said accident and loss above stated to the extent of the payment above made; the undersigned agrees that the Allstate Insurance Company may enforce the same in such manner as shall be necessary or appropriate for the use and benefit of the Allstate Insurance Company, either in its own name or in the name of the undersigned; that the undersigned will furnish such papers, information or evidence as shall be within the undersigned's possession or control for the purpose of enforcing such claim, demand or cause of action; that the undersigned will do whatever else is necessary to secure such rights of recovery on - behalf of the AIls tate-Insurance Company anddo-oothing after-loss to prejudice thern;and __u .. ~__. .__ The undersigned covenants that no release or settlement of any such claim, demand or cause of action has been made. Any person who knowingly and with intent to defraud any insnrance 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 ~aterial thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. IN WITNESS WHEREOF I have set my hand this day nf , A.D. Witnesses: (Signature) (Signature) STATE OF COUNTY OF } SS On this day of , before me personally appeared . to me known to be the person who executed the foregoing instrument, and acknowledged that executed the same as free act and deed. My commission expires Notary Public. C560 VERIFICATION I, the Petitioner, Debra Donmoyer McClain, an Executrix of the Estate of Louise Donmoyer, hereby verify that the statements set forth herein are true and correct to the best of my knowledge, information and belief. I am satisfied that the offer of structured settlement, referred to in this Petition, for Ms. Donmoyer's injuries is just and reasonable and I am willing to accept that offer. I have reviewed the contents of the Petition for Approval of Underinsured Motorist Level Two Settlement and concur with all the facts and statements. I understand that intentional false statements herein are made subject to the penalties of 18 Pa. C.S. 134904 relating to unsworn falsification to authorities. Date: rzj;;Z-/b{ D~!~?!J~ of the Estate of Louise Donmoyer VERIFICATION I, the Petitioner, Gary Donmoyer, an Executor of the Estate of Louise Donmoyer, hereby verify that the statements set forth herein are true and correct to the best of my knowledge, information and belief. I am satisfied that the offer of structured settlement, referred to in this Petition, for Ms. Donmoyer's injuries is just and reasonable and I am willing to accept that offer. I have reviewed the contents of the Petition for Approval of Underinsured Motorist Level Two Settlement and concur with all the facts and statements. I understand that intentional false statements herein are made subject to the penalties of 18 Pa. C.S. !:j4904 relating to unsworn falsification to authorities. Date: /;;'/2 -/0 S ~~~ Gary nmoyer, as ecutor of the Estate of Louise Donmoyer CERTIFICATE OF SERVICE AND NOW, this<iiU!! day of ~k , 2005, I, Gerard C. Kramer, Esquire, hereby certify that I have this day served the foregoing Plaintiffs Petition for Approval of Underinsured Motorist Level Two Settlement and proposed Order by depositing a copy of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania, addressed to: Tim Shaffer AllState Insurance Company 6345 Flank Drive, Ste. 1000 Harrisburg, Pa 17112 Gary Donmoyer 1074 Lancaster Blvd., Apt. 3 Mechanicsburg, Pa 17055 Debra Donmoyer McClain 2 Wheatfield Drive Carlisle, Pa 17013 SCHMIDT, RONCA & KRAMER, P.C. ~ erard C. Kramer Attorney at Law Attorney LD.# 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs