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COMMON PLEAS No,
95-7194 Civil Term
COMMONWEALTH OF PENNSYLVANIA
,
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
JUOICIAL OISTRICT
09-1-01
NOTICE OF APPEAL
FROM
DISTRICT JUSTICE JUDGMENT
NOTICE OF APPEAL
Notice is given that the appellant has filed in tho auovo Court at Common Picas an DPflCal from the judgment rendered by tho District Justice
on the date and in tho case mcntioned below.
M"W. O"-~"".""A'n
"'...0'11'. "D. ." H".. O. ..1,
Charles A. Clement, Jr. 09-1-01
The Harvest Life Insurance Company
.00..... 0,. ...........,,1'
City
ITA,..
II. co...
17055
4940 Ritter Road, Suite 105
Mechanicsburg
PA
S'fI"..rure of P,orhonora,'I Of Orpury
Insurance Co.
.ATS 01' 'UIlCi...."',.
'N T"'. c... a.. '"'.~'''''
12/5/95
Christine M. Layman
C...,... NO.
CV 19
L T 19
TIllS hlock will be signed ONLY when this notation is
R,C.P,J,P. No. 10088,
This Notice of AIJpcal, when received bV the District Justice, will 01 . ate.
a SUPERSEDEAS to the judgment for possession in this case.
441-95
w.. Claimall1 lsee Pa, R,C,P,J,P,
(6) in iJCtion before District Justice, Ire
FILE A COMPLAINT withIn twenty (20)
ay. after filing hi. NOTICE of APPEAL.
PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE
IThis section 01 form to be used ONL Y when appellant was OEFENDANT lsee Pa, R,C,P,J,P, No, 1001111 in action before Di.trict Jus/ice,
IF NOT USED, detach frolll copy of notice of appeal to be serve,'upon appellee),
PRAECIPE: To Prothonotary
Christine M. Layman
Enter rule upon
RULE: To
Christine M. Layman
N.mo o( appellee's}
, appelleelsl
/'
/
/ . appellee(s), to file a complaint in this appeal
Name of aPPfJllettfll
(Common Pleas No, 95-7194 Civil Term I with ill twenty (201 days after
ntry of IUdgment 01 non pros,
(1) You are notified that a rule is hereby entered upon you to file a complaint in this appea~within twenty (201 days afte' the date of
service of this rule upon you by personal service or by ccltifieu or rcgisterod mail. //
. / /
(21 If you do not file a complaint within this time, a JUDGMENT OF NON fROS WI LI..liE ENTERED AGAINST YOU,
(3) The date of service of this rule if service was by mail is the dalu of maili~
O.t.: Dec. IB
.19....2..5
"'OPe 312'90
coum IIUo I( I ill-. FILED Willi PHal HONOTAFlY
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-
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF: CUMBERLAND
.....l>tlNo'
1
NOTICE OF JUDGMEt-fTrrRANSCRIPT
,
PLAINTIFF: NAM'
I!.AYMAN, CHRISTINE"'~
555 E. BUTTER ROAD .
YORK, PA 17402
L
-.
09-1-01
I
OJ N.....; Holt.
CHARLES A. CLEMENT,
~, 1106 CARLISLE ROAD
CAMP HILL, PA
JR.
...J
DEFENDANT: VS.
r;; NAME... AOCIlElI8
THE HARVES~ LIFE INSURANCE
4940 RITTER ROAD
SUITE 105 "
~ECHANISBURG, PA 17055
Docket No,: CV-0000441-95
Date Flied: 10/31/95
...J
,
17011'
CO.
I
,
t
r.......,(7171761-4940
ATTORNEY DEF PRIVATE
1-1. G
JOHN NOBLE. '6
MEYER DORRAGH
114 S. MAIN STREET
G~EENSBURG, PAL15601
/112- 8JG. - L/~'tc.
THIS IS TO NOTIFY YOU THAT:
Judgment: -:::0 . .
[!] Judgment was entered for: (Name)
[!] Judgment was entered against: (Name)
.
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DEF:Al!L~ ~UDGMENT. PLTb.l,
J,
LAYMAN. CHRISTINE M.
THE HARVEST LIFE INSURANCE CO.
In the amount of $
3.248.80
(Dale) 12/05/95
on:
o Damages will be assessed on:
(Date & Time)
.;
o This case dismissed without prejudice,
o Possession granled,
O Possosslon Qrenlod " monoy Judgmontls nOI
satlsflod wfthln thlny doys,
o Posaoallon IlOI granted,
o Levy Ia 11IIyed lor _ dayl or 0 gilnotaily IlllYod,
o 0bjec:I1orl to leVY haS ~,NIcI ~.~IQ.~.be 1leId:, ..
0810: PlaCe:
~
Amount tJI Judgment
Judgment Costs
Inleros. on Judgment
Allornoy Fees
.
,
TOTAL
$3,189.00
$59.80
$.00
$.00
$3,248.80
.
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Timo:
ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS OF TH
OF APPEAL WITH THE PROT~ONq;rARY 1 CLI1~ OF COUR
12-5-95 Dalo ~
riel Justice
I cenlly thatlhls Is a true a
12-5-95 Date
My commission expires lIrst Monday 01 January, 1996,
SEAL
AOPC 315,95
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III DB COURT 01' COHKOH PLUS 01' CUMBBRLAHD COUNTY, PBmfSYLVUlIA
CIVIL ACTION - LAW
CHRISTINE LAYMAN,
Plaintiff
No. 7194 of 1995
PROOI' 01' 8BRVICB AND RULB
TO I'ILB COHPLAIHT
vs.
THE HARVEST LIFE
INSURANCE COMPANY.
Defendant
Filed on behalf of:
Defendant, The Harvest
Life Insurance Company
COUNSEL OF RECORD FOR THIS
PARTY:
HEYER, DARRAGH, BUCKLER,
BEBENEK & ECK
114 SOUTH MAIN STREET
GREENSBURG, PA 15601
JOHN H. NOBLB, BSgUIRB
Pa. I.D. #36933
(412) 836-4840
.
.
PROOF OF SERVICE OF NOTICE OF APPEAL AND MULE TO FILE COMPLAINT
(This proof of sorvico MUST BE FILED WITHIN TEN (10) DAYS AFTER /ifing tho notico of oppoa/, Chack applicablo boxos)
COMMONWEAL TH OF PENNSYLVANIA
WESTIIORELAND
COUNTY OF ;"
AFFIDAVIT: I herchy swear or aftirm thilll served
j[J
a copy uf the Notice 0' AplJcal. Common Plt~as No. ~lLJ!L,1J\9..f-l the District Justice designated therein 011
(daw of st...rvice) December 2~. 19..9L. 0 hy pcrsollalscr\licl! KJ by (cl!rtified) (registered) mail, sende,'"
{feci,)t 1I11aclwghcrclO. and upon the appelhm, (nomIC} Christine LO"y.!M;IJ___ . 011
ecember 2 t . lD~[J hy pCISClIHl1 ~fHVICC El hy (certified) hHuistCIIHJ) mail, sender's receipt attached hereto,
r~
and further that I served the Rule tn File a CUl11plill1lt accol11l>anyin!l the i1hovu Notice 01 Appelll upon the appcllcchl to
whom the Rule was addressed on December 2~_. 19-22-. 0 hy pCfsonal service ~J hy (certified) hC!listmedl
mail, sender's reccipt ullachcd heroto.
e
SigniJfUTL' of ilflialll
TirlllOfufllC:/iJ1
My commission l)xpiws on July 26..
. 19--!!6.
~SeoI
1l.'lIbara B I<ca.'. ~J1/'( PI.tk
Groorl3t\.q,;, 'nos~"tY..m!a'U Co:ulty
MyCon1l1"'''''''E'''''.....oM':l6,l996
n'o)t-'Wca ," iW1 cI ~,4)S
..aa"..' a, .,".""....,
cu.,
I'.'.
I.~ caa.
17055
.
COMMONWEAL TH OF PENNSYLVANIA
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
JUDICIAL DISTRICT
09-1-01
NOTICE OF APPEAL
FROM
OISTRICT JUSTICE JUDGMENT
COMMON PLEAS No,
95-7194 Civil Term
NOTICE OF APPEAL
NotIce is {lIven that the oPfJel!ant has filed in the above Court o' Common Picas on aPlleal hom the judgment rendered by the District Justico
on the datu and in the case mcntioned helow.
ii'i'iia'O"-A~~.I.I."'"
......0.1'. "a. aft ...... a~ D.'.
Charles A. Clement. Jr. 09-1-01
The Harvest Life Insurance Company
4940 Ritter Road. Suite 105
Hechaniuburg
PA
12/5/95
Chrbtine H. Layman
Inaurance CO.
D..1'. 0" lua.....,,1'
." 'tH. CAI. O~ ....or'"
C"...... JiO.
CV19
LT19
This. hlock will be signed ONLY when this notation is
R,C,P,J.P, No. 100BB,
This Noticc of Appeal. when received by the District Justice, will 0
a SUPERSEDEAS to the judgment for lJu5sussioll in this case.
441-95
S,gnature of P,orllunor,JrY ur Ocpury
/.
/J,f- a""ella, was Claimant lsee Pa, R,C,P,J,P,
/
No. 1 (6) in action before District Justice, ho
/ MUJY FILE A COMPLAINT within IWellty 1201
/
,,<fays after fi/illg llis NOTICE of APPEAL,
L/
PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE
IThis sectioll ollorm to he used ONL Y whell a""ellallt was DEFENDANT Isee Po, R,C,P,J,P, No, /001(1) in actioll hefore District Justice,
IF NOT USED, detach from COIJY 01 "oeice 01 .1"poiJl eo be !l!rvccl UpOll appellee).
PRAECIPE: To Prothonolary
,
\
Enter rule upon Christine H. Layman , appellee;t.I, t 'Iile a complaint in this appeal
N.,m" of iJppeUeefd'
(Common Plea. No, 95-7194 Civil Term I within twenty (201 day. aft~r .ervice 01 rule or .uffer ntry of judgment of non pro.,
. J / J ----
. .
S;gn6tll,. of app"tlanr or hi'.trornoy or age'"
/
/
Christine K. Layman
RULE: To
Namo o{ iJppellct'lsJ
, appellee Is)
(11 You arc notified that a rule is hereby cntcrec..l UIJO" you to file 0 complaint in this appeal within twenty (20) days after the date of
survicc of this rule upon you by personal setvice or by certified or registered mail.
(21 If yon do not file a complaint within this time, a JUDGMENT OF NON PROS WI Lk BE ENTERED AGAINST YOU,
/
(3) The date of service of this rule if service was hy mail is the dato of maili~
Dale: Dec. 18
. 19...21l
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AOPC 31 ~,!lO
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~ Receipt for
~ Certified Mell
No I",urane, COVlr.ge Pro\'lded
.... Do not u.. for Intern.tion.l Mill
ISH R,vi'.11
~<<ristine K. Layman
Z 231 bOb 92S
~ Receipt for I
Certified Mall !
_ No Insur.nc. COV"lgI ProvldeQ
.car1A\ Do not U'I for Internatlon.1 M.il
. .. es.. Revl,.e}
12 Ifl'll to
! Charles A. Clement r.
1! 111'Sn'fct Justice
i ',0. ScaltlN liP COde
g 11 ar
CD tlllllt> Hill, PA $
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12/20/95
12/20/95
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IN TIlE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
CHRISTINE M. LAYMAN
No. 95.7194
No. 95.7195
VB.
TIlE HARVEST LIFE
INSURANCE COMPANY
CIVIL ACTION. LAW
NOTICE
YOU HAVE BEEN SUED IN COURT. IF YOU WISH TO DEFEND
AGAINST THE CLAIMS SET FORTH IN THE FOREGOING PAGES, YOU
MUST TAKE ACTION WITHIN TWENTY (20) DAYS AFTER THIS
COMPLAINT AND NOTICE ARE SERVED BY ENTERING A WRITfEN
APPEARANCE, PERSONALLY OR BY AN ATIORNEY, AND FILING IN
WRmNG 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 MAYBE ENTERED AGAINST YOU BY THE COURT WITHOUT
FURTHER NOTICE TO YOU 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.
LAWYER REFERRAL SERVICE
COURT ADMINISTRATOR
CUMBERLAND COUNTY COURT HOUSE
CARLISLE, PA 17013
(717) 24CJ.6200
.
A VISO
USTED HA SIDO DEMANDADO EN LA CORTE. SI USTED
DESEA DEFENDERSE DE LAS QUEJAS EXPUESTAS EN LAS PAGlNAS
SIGUlENTES, DEBE TOMAR ACCION DENTRO DE VElNTE (20) DlAS A
PARTIR DE LA FECHA EN QUE RECIBIO LA DEMANDA Y EL AVISO.
USTED DEBE PRESENTAR COMPARECENCIA ESCRITA EN PERSONA 0
POR ABOGADO Y PRESENTAR EN LA CORTE POR ESCRITO SUS
DEFENSAS 0 SUS OBJECIONES A LAS DEMANDAS EN SU CONTRA.
SE LE A VISA QUE SI NO SE DEFIENDE, EL CASO PUEDE
PROCEDER SIN USTED Y LA CORTE PUEDE DECIDIR EN SU CONTRA SIN
MAS A VISO 0 NOTIFICACION POR CUALQUIER DlNERO RECLAMADO
EN LA DEMANDA 0 POR CUALLQUIER OTRA QUEJA 0 COMPENSACION
RECLAMADOS POR EL DEMANDANTE. USTED PUEDE PERDER DlNERO,
o PROPIEDADES U OTROS DERECHOS IMPORTANTES PARA USTED. '
LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAMENTE.
SI USTED NO ATIENE 0 NO CONOCE UN ABOGADO, VAYA 0 LLAME A
LA OFICINA EN LA DlRECCION ESCRITA ABAJO PARA AVERIGUAR
DON DE PUDE OBTENER ASISTENCIA LEGAL.
LAWYER REFERRAL SERVICE
COURT ADMINISTRATOR
CUMBERLAND COUNTY COURT HOUSE
CARLISLE, PA 17013
(717) 240-6200
"....~..._~....~~~~._" .' "'."h..,...".._.~",,,...,...:.._,;.,.,,,(j"V..,~,,"~'-";'-.....-..~.~.'..;,'-:~"~f_...'-, """,,,,,.':,=;":'.'';:':':i''''-''~.\;..~:'l'''''''''''';..~:;#~~~b''~,....-.--v
.
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
CHRISTINE M. LAYMAN
:
:
:
:
:
No. 95.7194
No. 95.7195
VI.
THE HARVEST LIFE
INSURANCE COMPANY
CIVIL ACTION. LAW
COMPLAINT
AND NOW, this 4th day oC January, 1996, comes the PlaintiCC, Christine M.
Layman, by and through her counsel, Joseph C. Korsak, Esquire, Korsak &
DeArment, and files the Collowing Complaint:
1. The PlaintiCC is an adult individual residing at 555 East Butter Road,
York, Pennsylvania 17402.
2. The Defendant is Harvest liCe Insurance Company, 4940 Ritter Road,
Mechanicsburg, Pennsylvania 17055.
3. PlaintiCC is an insured under a certain policy oC insurance issued by
DeCendant to PlaintiCrs husband, Richard Layman. A copy oC the agreement is
attached and rnarked Exhibit "A".
4. PlaintiCC was treated in 1994 for peritonitis which eventually resulted in
a hysterectomy.
.
S. Plaintiff received the following treatment and services:
a. Apple Hl1I Surgical Associates
2S Monument Road
York, PA 17403
08/18/94
$1,335.00 (See Exhibit "B" Attached)
b. York OB/GYN Associates, Ltd.
1399 South Queen Street
York, PA 17403
08/18{94
$1,854.00 (See exhibit "C' Attached)
c. York Hospital
1001 South George Street
York, PA 17405
08/18/94 to 08/24/94
$6,642.15 (See Exhibit "0" Attached)
6. Plaintiff rnade timely application for benefits under the policy of
insurance.
7. All bills have been presented to the carrier and all pre-conditions for
coverage have been rnet.
8. Despite demand, the Defendant refuses to make payrnent pursuant to
the terms and conditions of the contract of Insurance.
.
WHEREFORE. PlalntlCC prays entry oC judgment against the DeCendants In
the sum of $9,831.15 plus costs oC suit,
RespectCully Subrnltted,
KORSAK & DeARME.NT~'"
.---
-~..
//
Date:
January 4. 1996
By:
AU.ITAyt.INTtRNAnONAl
CA940406.AOI
.
ADlAlNlllmA TIVE OffiCE
6271 SEA HARBOR DRIV/!
ORLANDO. FLORIDA 32IlI7
.
~
HOME OFFICE
COWMBUB, OHIO
The Harvest Life Insurance Company
tAn 01110 S10dI Corplnllan)
MAJOR MEDICAL POLICY (FAMIlY)
POLtCY NUllbLR EFFECnVE DATE
lDZ6H51 07-19-1993
PRI"ARY lIlSURED - RICHARD A LAYMAN
ADDRESS - 555 UUTTER ROAO
YORK, PA
Zl PCOOE - 1 7~OZ
PRE "lUll
INITIAL - 'B53.96
RENEWAL - 'B33.96
TER" IN IIOS - 03
AGE - 3Z
DEDUCTIBLE A"OUNT - '1,000.00 "AXIHUH LIFETI"E A"T - '1,000,000.00
COINSURANCE LI"IT - ,aoo.oo OPTIONAL MATERNITY BENEFIT - NO
MAXI"U" IUTAL DISABILITY PERIOD - 1 YEAR
WEEKLY 0 SABILITY INDE"NITY - 150.00
PRINCIPAL SUM ANO OfATH bENEFIT - ,10,000.
AGENT - ( 03781 )
STEPHEN O'NEILL
*AT AGE 55, IIENEFl1 kEllUCES TO 15,000:
AT AGE 60, bENEFIT REDUCES TO U,500;
AT AGE 65, UENEFIT IS TER"INATEO.
FUR" - H"FPo/aIlPA
HOW TO FILE A CLAIM
In cue nrtoss ror which claim ilto be made, nOliry in wtiling:
The: 1I.",..ll.Ile Insul'lUlCe Com(Ulny
AlIn: Claims J)cp'.
6277 Sea lIarbor DIM:
Orlando. Florida 32887
Be sure 10 stale:
(a) Vour comple.e policy numbn;
(b) Your prescnl address;
(c) Da.e 01 Injury or Slckn... and na,un: 01 Loss;
(d) Name and address 01 allendlnal'hyslclan;
(c) Name and address 01 lIospi.al. II you were c:onOncd.
Wrillen notice 01 claim must he: Ii"" wilhin .he'lme period 'talCd In .hls poUey an" Ihe ClIX1IrRIlCe or COII1IIlCIlCClOI
01 any Loss covered by .hl. poliey,
EXHIBIT
A
Page 16
CA940406,AOl
1M]
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_ lWMn un IHIUlW1C1
,. APPliCATION TO: HOIII "',ICI: CDU....U.. OHIO
lJQ un II" HAMOR DRift
OIILANOO. n. JlIIJ
o HIW .....tHIN 0 CONYI",ION C ADOrTlON IH'URAHCI
N! 2755612
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Page 2
,
ADMINISTRATIVE OFFICE
8277 SEA HARBOR DRIVE
ORLANDO, FLORIDA 32887
, "
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HOME OFFICE
COLUMBUS, OHIO
The Harvest Life Insurance Company
(An Ohio Stock Corporation)
MAJOR MEDICAL POLICY (FAMILY)
THIS POLICY PROVIDES BENEFITS FOR LOSS DUE TO INJURY OR SICKNESS AS HEREIN UMITED AND
PROVIDED, THIS POLICY TERMINATES ON THE POLICY ANNIVERSARY FOJ.J.OWING A TI AINMENT OF
AN AGE QUALIFYING YOU TO BE ELIGIBLE FOR MEDICARE, THIS POI.ICY IS NON.PARTICIPATING.
In Ihis policy the Insured is also called "you" or "your," The Ha/Vest Life Insurance Company is called "us," "we." "our"
or "Ihe Company," The "Definitions" seclion de lines olher words and lenns used in Ihis policy,
In consideralion of your payment of premiums for Ihis policy. the Company insures you and all Insured Persons against
Loss caused by Injury or Sickness as herein limiled and provided, Coverage is provided subject to the lenns of this policy,
The amount of the first premium and the Effective Date of )'our policy are shown in Ihe Schedule of Policy Infonnalion,
This policy is a legal contract between you and the CIlmpany, READ YOUR POLICY CAREFULLY,
RIGHT TO EXAMINE POLICY FOR 30 DAYS
You have 30 days after receipt of this policy to examine its provisions, During that 30.day period. if you are dissatislied
with the policy. it may be relurned to Ihe Company al its Home Office, The Harvest Life Insurance Company. 6277 Sea
Harbor Drive, Orlando. Florida 32S87; to any stale office of Ihe Company, or 10 Ihe agent it was purchased from, 1m.
mediately upon such return this policy shall be void from the beginning and any premium paid will be refunded,
Ql',\UFIED RIGHT OF RENEWAl.
Vou have the righlto renew this policy. for conseculhe terms, by the payment oflhe required premium before Ihe end of each
Grace Period, V ou have the righlto renew this polky regardless of chang<os in your physical. mental or hC'dhh conditions, Vour
right to renew this policy is subje<1 only to the Company's right to non-renew this policy on the next premium due date following
the date the Company gives wriuen notice of its intent nOlto renew all polickos issued on this form in y.ourslate of residence, The
Company will give you alleasl60 days advance notice in writing prior to non-renewal of this policy, ..\ny non-renewal shall be
wilhoul prejudice 10 any claim originating while this polky is in force,
PRE:\IIUM AGREEMENT
Premi~ms for Ihis policy will inc~ase perio~icall~ due .to Ihe increase in your age, Upon attainment of an age requiring
a rale, mc~ase. Ihe renewal p~mlUm lo~ thiS pol~cy Will be the renewal premium Ihen in effect for your auained age,
PremIUm mcreases du~ to a~tamed age Will ~ake elfect on the p?licy anniversary following your binhday, Premiums may
?Iso be changed for,thls pohcy on any premIUm due dale. proVided premiums for all policies issued on this fonn number
m your stat~ of,resld~~ce are also chan,ged. For any nonscheduled premium change, we will give you at least 30 days
adv,anc~ notlc~ m wnlmg o~ such pn:mlUm chan,ge, Each renewal premium for this policy will be due at the end of the
penod lor.whlch the precedmg premIUm was paid, Renewal premiums shall be payable by you or on vour behalf at our
Home Olllce, .
IMPORTANT NOTICE
Please re:ld Ihecopy of the appliC'dtion auached to this policy, Omissions or misstatements in the application could cause an
otherwise valid claim to be denied, Carefully check theapplication and write to The Har...est Life Insurance Company. 6277
Sea Harbor Drive. Orlando. Florida 32887. within 10 days of the receipt of this policy if any information shown on it is not
correct and complete or ifany past medical history is ieI'I out oftheapplk:uion, ThisappliC'dlion is pan of the policy and this
policy was is.sued on the basis that the answers hI all4ueSlionsand the information shown on theapplk"Utionarecorrect and
complele to thc llI.ost of the applk"Unt's knowledge and helief.
Form MMFP-ll,8S PA
Page I
60774
TABLE OF CONTENTS
Page
Benefits ....,.., ......., ..................' ....,..,.....,'.., ......,....',.. 5-8
A. Injury and Sickness Benefit .......,..............,..........,5
B. Emergency Outpatient Accident Benefit....,......, 6
C. Mastectomy; Prosthetic Devices Benefit............ 6
D, Mental Illness. Nerv'ous Disorders and
Drug Dependency Benefit.................................. 7
E. Extended Care Facility and Skilled
Nursing Facility Benefit....................................... 7
F. Total Disability Income Benefit.....................,.... 7
G, Accidental Death
and Dismemberment Benefit............................., 8
Page
Conversion Provision,..,......,..,..,...... ......"...,..,......,.... 9
Definition",......,.. ......,....""..,'...,..,..,..,..,..........,...." 2-5
Exclusions,...."..,..,..,...."....,....,.."..,..,..,......"..,......,.., ,6
How to Filc a Claim ....,.............,.............................12
Policy Provisions....,.,....",..,....,..,..,..,..........,......, 10-1 I
Premium Agreement..............................................., I
Renewal Agreement..,..............,..,.........................", I
Schedule or Policv Inrormation..............................,12
Table or Contents...................................................., 2
Termination or Coverage......................,..................,,9
DEFINITIONS
Ambulatory SurgIcal Center
means a racility not located upon the premises or a hospital which provides outpatient surgical treatment. Ambulatory
Surgical Center does not include individual or group practice offices or private physicians or dentists unless such offices
have a distinct pan used solely ror outpatient surgical treatment on a regular and organized basis. A raCililY existing ror
the primary purpose or pert'orming therapeutic abortions shall not be construed 10 be an Ambulatory Surgical Cenler. Out-
patient surgical treatmenl means surgical treatment to palients who do not require hospitalization. but who require constant
medical supervision rollowing the surgical procedure pert'ormed,
Coinsurance Umll
means the maximum amount or Eligible Medical Expenses, exclusive or lhe Deductible, you will be required 10
pay in anyone calendar year. This Coinsurance Limit is shown in the Schedule or Policy Inrormation,
Coinsurance Share
means lhe Eligible Medical Expenses incurred by an Insured Person in each calendar year ror which that Insured
Person is required to pay, exclusive or the Deductible.
Common Accident Deductible
If twO or more Insured Persons are injured in the same accident. only one Deductible will apply to all the Eligible
Medical Expenses they incur in the calendar year in which lhe Injury occurred as a result or that accident.
Complication or Pregnancy
A Complication or Pregnancy is a Sickness under this policy.
A Complication or Pregnancy means:
(a) conditions requiring medical treatment prior or subsequent 10 the tcrmination or pregnancy whose diagnoses
are distinct rrom pregnancy but which are adversely arrected by pregnancy or caused by pregnancv. such as
acute nephritis. nephrosis. cardiac decompensation. missed abortion. disease or the vascular. hemopoieatic.
nervous. or endocrine systems. and similar medical and surgical conditions or comparable severity: but will
not include raise labor. occasional spOiling. physician prescribed rcst during thc pcriod or pregnancv.
morning sickness and similar conditions associated with the management or a difficull pregnancy not
constituting a classifiably distinct complication or pregnancy: and
(b) hypcrcmesis gravida rum and pre-eclampsia requiring hospital confinement. ectopic pregnancv which is
tcrminated. and spontancous termination of pregnancy which occurs during a period or gcstation in which a
viable birth is not possible: and
(c) conditions rcquiring medicaltrealment after the termination or pregnancy whose diagnoses are distinct rrom
pregnancy but which arc adversely arfected by pregnancy or caused by pregnancy,
A Com plical ion or Pregnancy docs not mean:
I. raise labor;
2. occasional spotting:
3, Physician prescribed rest:
4. morning sickness:
5. .other conditions connected with n difficult pregnancy not being :1 sepnrllte scientifically classified
Complication or PregnancY'L
Form MMFP-8/88 PA
Page 2
\,.
fi
()
Deductible
means the amounl of Eligible Medical Expenses that must be incurred by an Insured Pl:rson in each calendar year
before benerilS will be pAyable. We do not pay lhis amount. The Deductible Is shown In the Schedule of Policy
Information.
Deductible c.rr1ed Over After September 30
Any Eligible Medical Expenses that are bOlh:
1. incurred after September 30; and
2. applied to an Insured Pl:rson's Deductible for that year but not sufricientto satisfy that year's Deductible wlll
also be applied to that person's Deduclible for the next calendar year. If the Deductible was satisried in the
previous year, no expenses will be carried over to satisfy the next year's Deductible.
Deductible Maximum
A maximum of three Deduclibles, for all Insured Persons, is payable in anyone calendar year.
E!lltble Medical Expenses
means those charges for medical services and supplies thaI are listed in the Benefit Section and are:
I. the result of Injury or Sickness incurred while the policy is in force;
2, performed or prescribed by a Physician;
3, Usual and Customary; and
4, not otherwise excluded from coverage.
Extended c.re Facility and Skilled Nursing Facility
means an inslitution which:
I. is operated pursuant to law;
2. is primarily engaged in providing, in addition 10 room and board accommodations, skilled nursing care on a
24.hour basis by or under the supervisiC'n of a licensed nurse:
3, provides medical care under the supervision of a licensed Physician: and
4. maintains a medical record of each patient.
A Skilled Nursing Facility is not:
I. any home. facility or part thereof used primarily for rest;
2. a home or facility for the aged or a facility primarily used for drug addiction or alcoholism; or
3, a home or facilily primarily used for custodial or cducational care.
Hospital
means an institution which:
I. operates persuant to law;
2. primarily provides medical care and treatment of sick and injured person on an inpatient basis:
3, provides 24-hour nursing service by or under the supervision of registered professional nurses,
Hospital does not mean any instilution which is primarily used as:
I. convalescent homes or convalescent, rest. or nursing facililies:
2. facilities primarily affording custodial or educational care: or
3. facilities for the aged.
Form MMFP-8/88 PA
Page 3
Injury
means accidental bodily injury which:
I. occurs while this policy is in force:
2. causes Loss while this policy 15 in force: and
3. does not result from disease or bodily inrirmity.
Insured Ptnon
means you and all persons named in the application for insurance. Persons eligible to become Insured Persons are:
I. you:
2. your spouse: and
3, your unmarried children, including stepchildren and any legally adopted children, If they are dependent upon
you for support and maintenance, and:
a) are less than 19 years old: or
b) are full time students less than 23 years old.
Intensive Care Unit
means that part of a Hospital specirically designed as an Intensive Care Unit permanently equipped and staffed
to provide more extensive care for critically ill or injured patients than available in other Hospital rooms or wards:
such care to include close observation by trained or qualified personnel whose duties are primarily confined to
such part of the Hospital for which an additional charge is made.
Llfellme Maximum Amounl
means the maximum amount we will pay for anyone Insured Person during that Insured Person's lifetime. This
Lifetime Maximum Amount is shown in the S~hedule of Policy Information,
Loss
means Sickness or Injury for which benefits are provided under one or more of the Benefit Sections,
Medicare
"The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Con-
stituted or later Amended", or Title I, Part I of Public law 39-97, as Enacted by the Eighty-Ninth Congress of
the United States of America and popularly known as the Health Insurance for the Aged Act", "as then constituted
and any later amendments or substitutes thereor'.
Mentallllneos and Nmous Dlsordm
Menllll. nervous or emotional disorders withoul demonstrable organic origin,
Physician
means any person duly licensed by law in the authority in which service or treatment is rendered, to treat the type
of Injury or Sickness causing Loss for which claim is made.
~xlstlng Condition
means any disease, illness, sickness, or condition which was diagnosed by a Physician prior to the Effective Date
with consultation, advice or treatment by a Physician occurring within 12 months prior to the Effective Date.
PrImary Insured
means the person 50 named in the application for insurance for this policy,
Usual and Customary Charge
mea~s the average charge made for the same service or supply in the same geographical arca by the same type of
prOVider.
Sickness
means sickness or disease which:
I. is diagnosed or treated after the Effective Date of this policy: and
2, causes loss while this policy is in force.
'\
,
Page 4
r--.
,
,.-
,
, .
Total Disability
meaDS that you are tOllllly diSllbled due to either Injury or Sickness. and:
I. are unable to perform all substantial and material duties of your regulnr occupation;
2. are not gainfully employed in any other occupation for wage or profit because of such Total DiSllbility; and
3. are under the regulnr care of a Physician because of such Total Disability.
PRE.EXISTING CONDITIONS LIMITATION
During the first 12 months this policy is in force, it docs not cover Loss caused by a Sickness or physical condition diagnosed by a
physician prior to the Effective Date. and for which an Insured Person sought or received consultation. advice or treatment by a
Physician within 12 months priorto the Effective Date, Aba not covered is Loss which is excluded by name orspecilicdescription,
BENEFIT SECTION
PART A-INJURY AND SICKNESS BENEFIT
If an Insured Person incurs a Loss due to Injury or Sickness while this policy is in force, and incurs any of the
Eligible Medical Expenses listed below, we will pay benefits to you, after the deductible has been satisfied. Once
the Deductible has been satisfied, we will pay 80010 of the Insured Person's Eligible Medical Expenses until the
Coinsurance Share has equalled the Coinsurance Limit for that Insured Person in that calendar year. After the
Coinsurance Share has equalled the Coinsurance Limit for that Insured Person in that calendar year, wc will pay
100010 of thc Eligible Medical Expenses incurred during that calendar year for that Insured Person, but not to exceed
the Lifetime Maximum Amount shown in the Schedule of Policy Information.
The Dcductible and the Coinsurance Share requirements will be applied only once to each Insurcd Person in any
one calendar year.
FJlgible Medical Expenses
I. Hospital room, board, and general nursing services, not to e"ceed the Hospital's slllndard scmi-private room rate;
2. In lieu of #1 above, Intcnsive Care Unit of a Hospital, not to exceed three timesthc Hospital's standard semi-
private room rate;
3. Misccllancous inpatient Hospital services and supplies;
4. Licensed Ambulatory Surgical Center services and supplies;
S. Charges by a Physician for surgical operations in a Hospital on an inpatient or outpatient basis or in a licensed
Ambulatory Surgical Center or Physician's office, including charges for:
a. ancsthesiologist; and
b. radiologist;
6. Physician's treatment, other than surgery, limited to one visit per day;
7. Charges by a Physician for rendering a second opinion regarding a proposed surgical operation, provided the
Physician rendering such second opinion is independent in practice from the first Physician who initially proposed
thc surgical operation;
8. Privatc duty nursing care by a registered graduate nurse, other than the Insured Person or a member of thc
Insured Person's immediate family, while an Insured Person is Hospital confined;
9. Charges for professional ambulance service to and from a Hospital or Ambulatory Surgical Center within a
lSD-mile radius of such facilities;
10. Charges for the treatment for Injury to sound, natural teeth: and
II. Charges for the mcdical care, treatment, services. and supplies listcd below:
a. x-ray examinations, microscopic and laboratory tests (including pre-admission Hospitaltcsts given to an
Insurcd Person in a Hospital or on an outpatient basis prior to Hospital admission), and other diagnostic
services;
b. trcatment by chemotherapy, x-ray, radium or other radioactivc substances:
Co casts, splints, braccs, crutches, and surgical dressings:
d. anlficiallimbs and eyes;
Co heart pacemaker;
f. rental (not to exceed the purchase price) of the follOWing: wheelchair, hospital bed. and oxygen equipment;
g. blood and blood plasma; and
h. physiotherapy by a licensed physiotherapist,
If any of the above Eligible Medical Expenses fall under more than one category, the expense will be considered
only once for bcnefits,
Form MMFNI{88 PA Page S
PARr B-EMERGENCY OUTPATIENT ACCIDENT BENEFIT
We will pay an Emergency Outpatient Accident Benefit if: '
1. an Insured Person has a Loss due to Injury while this policy is in force: and
2, the Insured Person is treated in a Physician's onice. clinic. or Hospital as an outpatient,
We will pay 80070 of the expenses actually incurred for:
I. Charges for professional ambulance service to and from a Hospital or Ambulatory Surgical Center within a
lSD-mile radius of such facilities;
2. Charges by a Physician for medical treatment, plus charges for I follow-up visit resulting from the same Injury;
3. Charges for the following services and supplies:
a. ,,-ray examinations and laboratory tests;
b. anesthetics and their administration;
Co operating or emergency room;
d. casts, splints, and surgical dressings;
Co drugs and medical ions administered in a Physician's office. clinic, or Hospilal.
The Deductible requirement will not apply to this Benefit.
PARr C-MASTECTOMY; PROSTHETIC DEVICES BENEFIT
We will pay benefits for prosthetic devices to maintain or replace body parts of an individual who has undergone
a mastectomy, This coverage provides that reasonable charges for medical care and attendance for an individual
who receives reconstructive surgery following a mastectomy or who is fitted with a prosthetic device shall be covered
for benefits after the individual's attending Physician has certified lhe medical necessil} or desirability of a proposed
course of rehabilitalive treatment. The cost and filling of a prosthelic device following a mastectomy is included
under this benefit.
Exclusions From Coverage Under Part A, Part B & Part C
This policy does not cover charges:
1. for treatment of an Injury or Sickness due to war or an aCI of war;
2. for treatment of intentionally self-innicted Injury or attempted suicide;
3. for treatment of an Injury or Sickness to the extent benefits are payable under any Worker's Compensation
or Occupational Disease law;
4. for dentures, dentistry, dental surgery, or denial x-rays, excepl for lhe treatment for Injury to sound. naturalleeth;
S. for eyeglasses, contact lenses, hearing aids, or for the e'lllmination for prescribing or filling them:
6. for services which the Insured Person is not. in the absence of insurJnce. required to pay:
7, for cosmetic care. treatment. or surgery. unless it is due to an accidenlallnjury or 10 correct binh abnonnalities or
defects;
8. for nonnal pregnancy and childbinh (unless the Maternily Benefit Rider is elecled):
9. for physical examinations that are not necessary for the diagnosis and treatment of an Injury or Sickness:
10, for drugs and medicines other than lhose included as inpatient hospital supplies (Pan A only):
II. for voluntary sterilization unless the Insured Person has been covered for over one year;
12. for treatment of Alcoholism:
13, for treatment ofMentallllness. Nervous Disorders (Wilhout demonstruble organic origin) or Drug Dependency excepl
as provided in Benefit Section Pan 0:
14, for trealment of un Injury or Sickness to the extent benefits are payable under aUlomobile insurunce first pany benefits.
Catastrophic Loss benefits paid by the Catastrophic Loss Trust Fund and any workers compensation benefits;
15. for Pre-existing conditions during the first 11 monlhs:
16. for any loss sustained or contrucled in consequence of any Insured Person being legally intoxicated or under the
influence of any narcotic unless administered on the advice of a Physician.
Form MMFI>-8f88 PA
,
Page 6
r~
PART D-MENTAL ILLNESS, NERVOUS DISORDERS AND DRUG DEPENDENCY BENEFIT
If an Insured ~rson has a Loss due to mental or nervous disorders or drua dependency we will pay 50'1. of the
expenses actually incurred for:
I. Hospital treatment; and
2. Physician's visits. not to exceed a maximum of S30 per visit. limited to one visit per day.
These benefits will not be paid until after the Deductible has been satisfied. The Part D Lifetime Maximum AmoUllt
payable for any Insured ~rson will be 55,000.
PARr E-EXTENDED CARE FACILITY AND SKILLED NURSING FACILITY BENEFIT
If an Insured Person has a Loss due to Injury or Sickness while this policy is in force and is confined in an Extended
Care Facility or a Skilled Nursina Facility, benefits will be paid provided:
I. the Insured Person was confined in a Hospital before his or her Extended Care Facility or Skilled Nursina
Facility confinement for at least three consecutive days for the same Injury or Sickness;
2. the Hospital and Extended Care Facility or Skilled Nursing Facility confinements were medically necessary in
the opinion of the Insured Person's Physician;
3. the Insured Person's Extended Care Facility or Skilled Nursing Facility confinement beains within 30 days after
discharge from the Hospital;
4. the Hospital confinement was an Eligible Medical Expense under this policy; and
5. the Extended Care Facility or Skilled Nursing Facility confinement is upon the advice of a Physician who is
not the owner, operator, or employee of the Extended Care Facility or Skilled Nursing Facility.
Ifthe above requirements are met. we will pay. for a period not to exceed 60 days. the expenses the Insured Person actually incurs.
The total Part E benefit payable shall not exceed 80% of the amount the Insured Person was charged for hospital room. board
(not exceeding the Hospital's standard semi-private room rate). and general nursing services. during his or her Hospital stay
before being transferred to the Extended Care Facility or Skilled Nursing Facihiy, These benefits will not be paid until after the
Insured Person's Deductible has been satisfied,
PART F - TOTAL DISABILITY INCOME BENEFIT
If Injury or Sickness shall result in your Total Disability, the Company will pay the Weekly Disability Indemni-
ty as specified in the Schedule of Policy Information. If you are totally disabled for a portion of a week, the
Company will provide benefits at the rate of one-seventh of the Weekly Disability Indemnity for each day of
such Total Disability.
The benefit period for each Injury or Sickness causing a Total Disability shall not exceed the Maximum Total Disability
Period as specified in the Schedule of Policy Information,
1btal Disability benefits will not be payable for a Total Disability which results from:
I. self.innicted injury while sane or insane;
2. war, declared or undeclared; or
3. normal pregnancy or childbirth (Complications of Pregnancy are not excluded).
No person other than the Primary Insured will be covered under this Pan F. Your spouse or other dependents are not covered
under this pan.
Form MMFP-8/88 PA
Page 7
PART G-ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT
If you have any Injury and as a result you die or suffer a dismemberment. we will pay for loss of:
Life....... ........ ..........., ......,.... ......, ......, .............. ....................,......'....,.. .........,..,.... ........." .........,.. ............ S 10,000
Both Hands...................................."....,......,....................................................................,.................... 10,000
Both Feet....,.........,..,....,..,....,..". ,..,..,...................,......,......,......,..."..,..,......................,........................, 10.000
Sight of Both Eyes.....................,......................,.........,......,........................................,......................... 10,000
One Hand and One Foot...............................,....,......,...."...........,....................................................... 10,000
One Foot and Sight of One Eye.......................................................................................................... 10.000
One Hand and Sight of One Eye ........................................................................................................ 10.000
Either Hand ....,....................,..........,............................,................."......................"....,..,..................... 5,000
Either Foot...................,........................................................................................................................ 5,000
Sight of Either Eye .........................,........................................,.....,....,................ ................................ 5,000
When you reach the age of 55. benefits under this item will be reduced 50%, When you reach the age of 60, benefits
will be reduced to 25%. Insurance under this benefit will terminate when you reach the age of 65.
If more than one of the above losses is suffered due to anyone Injury. only the larger amount will be payable. Uthe
benefit is payable because ortoss of life. it will be paid to your beneficiary. Other benefits payable under this part will be
paid to you.
Loss of hands or feet shall mean complete and permanent sever-mee at or above the wrist or ankle joints: loss of eyes or
eye shall mean complete and permanent blindness.
Exclusions From Coverage
This benefit does not cover accidental death or dismemberment which results from:
I. self-inflicted injury or suicide while sane or insane: or
2. war. declared or undeclared.
COVERAGE FOR NEWBORN AND DEPENDENT CHILDREN
Coverage for newborn children. while this policy is in force. will be automatically added at birth to the extent of the
provisions in this policy including the necessary care and treatment of medically diagnosed congenital defects. birth
abnormalities. prematurity. and routine nursery care, Such coverage shall be provided for the 31-day period after
birth. within which time the Primary Insured may submit application to continue dependent coverage, If a person
otherwise becomcs eligible for coverage as a dependent after this policy has been issued. such person shall become an
Insured Person when:
I. we approve your written application for coverage for that person: and
2, we receive payment of any required premium.
Form MMFP-8/88 PA
l....
Page 8
(
-
,
ELIGIBILITY
The members of the Primary Insured's family who are eligible for coverdgc include (I) 'PIlUse: (2) unmarried children
including adopted children (including children pending adoption or in the process of being adopted, provided the child is
legally in the Primary Insured's custody). if they are dependent upon the Primary Insured for support and maintenance.
and: (a) are less than 19 years old: or (b) are full-time students less than 23 years old,
TERMINATION OF COVERAGE
Your insurance and that of all Insured Persons shall terminate upon the occurrence or the first of the following events:
I. the required premium is not paid within the grace period: or
2. the policy annivenary following your altainment of an age qUlllifying you to receive Medicare.
The Insurance 0' an Individual Insured Person shall terminate upon the occurrence of the first of the following events:
I. the required premium is not paid within the grace period; or
2 the policy anniversary after the Insured Person no longer meets the eligibility requirements, unless the Insured
Person is incapable of self-support due to mental retardation or physical handicap; or
3. the policy anniversary following the Insured Person's attainment of an age qualifying that Insured Person to
receive Medicare.
If a premium is accepted for an ineligible person after a termination dale. cllverage Wilh respect to such person will be provided for
the period for which premium has been accepted, unless the renewal premium is nOI subject to change by reason ofterminalion of
co\'Crage for such ineligible person. except where such acceplance was predicated on a misstalemenl of age,
Iftennination of coverage occurs by reason of non-renewal ofthis policy. while an Insured Person is totally disabled. coverage shall
continue for a period of90 days beginning with the day following the date oftermination or non-renewal. pertaining solely to the
Injury or Sickness which caused the TOlal Disability,
CONVERSION PROVISION
A. If an Insured Person's coverage should terminate because:
I. you and your spouse are divorced or your marriage is annulled;
2. a child has reached the limiting age for dependent coverage (unless the child is incapable of self support due
to mental retardation or physical handicap, in which case no termination shall occur);
3. a child is married;
4. you have attained an age qualifying you to be eligible for Medicare and this policy terminates. provided the
Insured Person is not eligible for Medicare;
The Insured Person will be eligible to purchase a conversion policy. provided:
I. the application and the required first premium is sent to us within 31 days after coverage under this policy ends; and
2. the Insured Person is living in a state in which we offer similar coverage.
The Insured Person will not have to give us proof of insurability. The conversion policy will provide coverage we
are then issuing that is most like the benefits under this policy. The conversion policy benefits shall not be greater
than the coverage ended. Any restrictions or periods of contestability that apply to the Insured Person under this
policy will also be applied to the conversion policy. The policy. if issued. will take effect on the day after the date
coverage under this policy ends.
If the Insured Person has not been notified of his or her right to convert at least IS days before the end of the
31-<lay period;
I. the right to convert will be e.~tended an additional 30 days, but;
2. in no event shall the additional period e.~tend beyond 30 days after the expiration of the 31.day conversion period.
B. If the Primary Insured dies while this polkoy is in force, the surviving spouse shall automatically become the
Primary Insured. All references to the Primary Insured in this policy shall then apply to the surviving spouse.
If there is no surviving spouse. all other Insured Persons shall have 90 days to purchase similar coverage without
giving us proof of insurability.
Form MMFP-8/88 PA
Page 9
Form MMFI'-H 881'A
J.,
P'dge 10
\
POLICY PROVISIONS
ENTIRE CONTRACT: CHANGES: This policy, including the endorsemems and the attached papers if any, con-
stitutes the emire contract of insurance. No cl;~..oc in this policy ..._;1 be valid until approved by one of our ex-
ecutive officers and unless such approval be endorsed thereon or attached thereto, No agent has authority to change
the policy or to waive any of its provisions.
TIME LIMIT ON CERTAIN DEFENSES: After 2 years from the date of issue of this policy no misstatements,
except fraudulent misstatements, made by the applicant in the application for this policy shall be used to void this
policy or to deny a claim for loss incurred or disability commencing after the e.xpiration of such 2 year period.
No claim for loss incurred or disability commencing after one year from the date of issue of this policy shall be
reduced or denied on the ground that a Pre-Existing Condition (as defined in the policy) not excluded from coverage
by name or specific description effective on the date of loss had existed prior to the Effective Date of coverage
of this policy,
NOTICE OF CLAIM: Written notice of claim must be given 10 us within 20 days after the occurrence or commencement of any
Loss covered by this policy. or as soon thereafler as is reasonably possible, Notice given by or on behalf of an Insured or the
beneficiary to the insurer at its Home Office. The Harvest life Insurance Company. Allenlion: Claims Dept.. 6277 Sea Harbor
Drive. Orlando. Florida 32887. or to any of our authorilcd agents. with information sufficient to identify the insured shall be
deemed notice to. us,
CLAIM FORMS: We will. upon receipt of a notice of claim. furnish to the c1aimam such forms as are usually
furnished by us for filing proofs of loss. If such forms are not furnished within IS days after the giving of such
notice, the claimant shall be deemed to have complied with the requiremems of this policy as to proof of loss upon
submitting, within the time fixed in this policy for filing proofs of loss, written proof covering the occurrence, the
character and the extent of the Loss for which claim is made.
PROOFS OF LOSS: Written proof of loss must be furnished to us at our said office in case of claim for loss for
which this policy provides any periodic payment comingem upon cominuing Loss within 90 days after the termina-
tion of the period for which we are liable and in case of claim for any other Loss within 90 days after the date
of such Loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if
it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably
possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise
required.
TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for any Loss other than Loss for which
this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such Loss.
Subject to due written proof of Loss, all accrued indemnities for Loss for which this policy provides periodic pay-
ment will be paid monthly and any balance remaining unpaid upon the termination of liability. will be paid im-
mediately upon receipt of due written proof.
PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance with the beneficiary designation
and the provisions respecting such payment which may be prescribed herein and effective at the time of payment.
If no such designation or provision is then effective, such indemnity shall be payable to the estate of the Insured
Person. Any other accrued indemnities unpaid at the Insured Person's death may. at our oplion. be paid either
to such beneficiary or to such estate, All other indemnities will be payable 10 the Primary Insured,
PHYSICAL EXAMINATIONS & AUTOPSY: At our expense, We shall have the right and opportunity to examine
any Insured Person when and as often as it may reasonably require during the pendency of a claim hereunder and
to make an autopsy in case of death where it is not forbidden by law,
LEGAL ACTIONS: No civil action shall be brought 10 recm.er on this policy prior to the expiration of 60 days
after written proof of loss has been furnished in accordance with the requiremems of this policy. No action shall
be brought after the expiration of 3 years after the time written proof of loss is required to be furnished.
~
"
ORACE PERIOD: Unless not less than 60 days prior to the premium due date we have delivered to the Primary
Insured, or have mailed to his or her last address as shown by our records. written notice of our intention not
to renew this policy beyond the period for which the premium has been accepted, a grace period of 31 days will
be granted for the payment of each premium falling due after the first premium. during which grace period this
pollcy shall continue In force.
REINSTATEMEN'r. If any renewal premium be not paid within the time granted the Primary Insured for payment,
a subsequent acceptance of premium by us or by any agent duly authorized by us to accept such premium, without
requiring in connection therewith an application for reinstatement, shall reinstate this policy: provided, however.
that If we or such agent requires an application for reinstatement and issues a conditional receipt for the premium
tendered, this policy will be reinstated upon approval of such application by us or, lacking such approval, Jlpon
the 45th day following the date of such conditional receipt unless we have previously notified the Primary Insured
in writing of our disapproval of such application. The reinstated policy shall cover only Loss resulting from such
accidental injury as may be sustained after the date of reinstatement and Loss due to such Sickness as may begin
more than 10 days after such date. In all other respects all Insured Persons and The Harvest Life Insurance Com-
pany shall have the same rights thereunder as they had under this policy immediately before the due date of the
defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstate-
ment. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium
has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement.
BENEFICIAR Y: Yau have the right to name lhe beneliciary for the Aecidenlal Death and Dismemberment Benelit, You
also have the right to change beneliciaries by notifying us in writing, The change will be erfective on the date that notice was
signed, The change is subject to any payment or actons we may have taken before receiving the notice,
If no beneficiary survives you, your estate will be the beneficiary.
CONSIDERATION: We have issued this policy to you in consideration of the payment of the initial premium and
the statements in the application. This policy takes effect on lhe Effeclive Date as specified in the Schedule of Policy
Information.
CONFORM ITV WITH ST ATE STA TUTES: Any pro,.ision oflhis policy which, on its elTcCli\edalc. is in conlliCI wilh
the slalUles of the stalC in which Ihe Insured resides .)0 such dale is hereby amended 10 conform with the minimum
requirements of such statutcs,
ASSIGNM ENT: When permiued by slale law. you may assign thc benelils Oflhis policy, The assignment will not be binding on
us until a wriuen copy of it is received at our Home OlTIce. We are nol responsible for Ihe validily of any assignment. The rights of
the beneficiary. if applicable. will be subject to the righls of any assignee,
M ISST A TEM ENT OF AGE: lfthe age oCthe insured has been misstated, all amounls payable shall be such as the premium paid
would have purchased at the correct age,
INTOXICANTS ~ND NA~COTICS: The insurers~all nOl be liable for any loss sustained orcontracled in consequence of any
Insured Person bemg legally mlOXlealed or under the mnuenee of any nareolic unless administered on Ihe advice of a Physician,
All periods of insurance begin and end al 12:01 A,M" Standard Time, at your place of residence.
IN WITNESS WHEREOF, The Harvest Life Insurance Company has caused these presenls to be signed bv its
Chairman and Executive Vice President. .
~f/P
J.
;v../l' Ql.-
J 1~
Chairman
EXICutivI Vice Pretidenl
Form MMFP-8/88 PA
Page II
ADMINIITRATIVI! OFFICE
1m llA HARBOR DRIVE
ORLANDO, FLORIDA 32887
))>>(({
HOME OFFICE
COLUMBUS, OHIO
The Harvest Life Insurance Company
(An Ohio Stock Corporation)
MAJOR MEDICAL POLICY (FAMILY)
HOW TO FILE A CLAIM
In case of Loss for which claim is to be made. notify in writing:
The Harvest Life Insurance Company
Attn: Claims Dept.
6277 Sea Harbor Drive
Orlando. Florida 32887
Be sure to state:
(a) Your complete policy number;
(b) Your present address;
(c) Date of Injury or Sickness and nature of loss;
(d) Name and address of attending Physician;
(e) Name and address of Hospital, if you were confined.
Written notice of claim must be given within the time period Slated in this policy after the OCCUrrence or commencement
of any .los~ covered by this policy.
'-
l
YORK OB/GYN ASSOCIATES, LTD.
1399 South Queen Street 3130 Grandview Ad.
York, PA 17403 Hanover, Pa 17331
ACCOUNT NO:
PAGE NO:
15840
1
BlllINGOATE: 02/27/95
DATE OF LAST PYMT: 12/02/94
PLEASE PAY ON OR BEFORE: 03/15/95
1854.00
Jam.. W. Smllh. M.D.
JIY R. J.cklOn. M,o.
0'11.1 H. a.rtach. MD
Mary O. Keperling. D.O.
ceboran J. Ashlon, M.S.N.. C.A.NP,
Chnsllne L. Gold. M,SN., C.R.N.P.
TAX I,D, .23.2118999
AMOUNT DUE:
AMOUNT ENCLOSED:
Christine M Layman
555 East Butter Rd.
York PA 17402
C~'R'3E UJOVNf OVE' TO !,tV
Cl UASTtACARO D VISA
II II 1rn:::IJ 1I1III11
PRINT
NAME:
I
EXP.OATE
SIGNATUFlE
DETACH ~O RETURN THIS PQRTICN WITH P.t,YMENT
STATEMENT FOR PROFESSIONAL SERVICES
CHARGES AND PAYMENTS RECEIVED AFTER THE ABOVE BILLING CATE WILL APPEAR ON YOUR NEXT STATEMENT,
DATE I PR?CEOUf1E 1 CItARGES ADJUSTMENTS I PAYMENTS I DALANCE II
08/18/94158150
Abdominal
I
I
I
Hysterectom~
.00ipatient
. Medicare
. Insurance
1854.00'
.00
.00
.00
1854.00
I
.. statement Due upon Receipt. ThanK You ..
l
* WE HAVE BillED YOUR INSURAlICE
ANY QUESTIONS: PLEASE CAllAND ASK FOR THE BilLING OFFICE AT (717) 854,0492
9Sl1feguard' ,..,.",.,
YORK 0
1399 South
. York. PA
TO
Rd
733
EXHIBIT
c
AU.1TAn.IHn~ATtONAl
02-10-58 08-19-94 08-24-94
PHYSICIAN
UA
OfIS
. ,
'. ,!~.
......1 \::-':~,~.~ .~-~;~~'~~'~':'~'t"" .~ "
- l'< ..... "~~~. (\,'l;"~7"" 1'".
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" .~ '., \ I . ., . ,
. ~ ..........."": _., jr, ll. ".
~.~ I r~ , . ~ 'J'" iIo. I". ,.
. '\. ,..... ."" . . ....... of '1'. toll .~.... . .,..
PATIENT NUMBER PAGe
LAYMA~,CH~ISTINE MAqlETTA
PT OOB SERVICES STARTED SfRVI ES OED
I
SOCIA1.5ECURITYNO I ~
191-48-4418i
FATHER B
COHHERC UL
218642840
OJ-IB-?5 SO
PATIENT NAUE
Sf NO
~
31
~
~
. .'f:~",,*
_.. . _u ~ .
"u..r..~,'~. ~'J'
609 GERLACH,OETLEF H.
GUARANTOR
218-64-2840
RICHARO LAYHAN
555 EAST 8UTTER RO
,:. :"' ~ I'"
,"
~1"~'~"
,.71\7.;',' . '
.u......... ,..... . --..,
PA 17402
CHARQES OR CREDIT
Summary of Charges
250/PHARMACY
300/LA80RATORY
120/ROOM-BOARO/SEMI
260/IV THERAPY
270/MEO-SUR SUPPLIES
410/qESPIRATORY SVC
3bOIOR SERVICES
370/ANESTHESIA/SUPPLIES
32010 X X-RA Y
402lULTRASOUNO
710/RECOVERY ROOM
310/PATHOLOGY LAB
259/0RGS/OTHER
725.35
262.95
1,896.00
289.50
130.75
57.75
2,099.40
397.flO
52.50
284.00
164.00
257.00
25.2:;
.s............
TOTAL
6,642.15
00-14-1994
03-14-1995
03-14-19?5
PAYMENTS PRIOR TO INVOICE OATE
COMMERCIAL INSURANCE
REJECTEO-CO~T^CT YOUR C^R~IER
0.00
0.00
0.00
WE HAVE 81LLEO YOUR INSURANCE.
^~OUNT SHOWN ~ELOW AS "DUE FROM
THANK YOU.
PLEASE PAY THE
PATIENT".
EXHIBIT
D
AU..ItATI-INTnNAnONAl
PATIENT NAUE
LAY~^~,CHRISTINE MARIETTA
PATIENT NUMBER ~ 18768564
PLEASE REFER TO THIS PATIENT NUMBER
ON All, INOUIRIES AND CORRESPONDENCE
IF YOU HAVE OUESTIONS REGARDING THIS BILL, PLEASE CALL I 71 71 8<; 1- 2544
SERVICE BY RADIOLOGISTS
ANESTHESIOLOGISTS AND
CARDIOLOGISTS ARE NOT
INCLUDED IN THIS BILL,
DUE FROM INSURANCE: 0 . O'
DUE~ROM YOU ~ 6,642.1'
PAYMENT DUE BY: 03-29-1?Q'
VERIFICATION
I, Christine M. Layman, do hereby certify that the facts set forth in the
foregoing instrument are true and correct to the best of rny knowledge, information
and belief.
Date: tJ!/05191J
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on this date a true and correct
copy of the foregoing document, was served by first-class rnall, postage
prepaid, upon the following:
John M. Noble, Esquire
MEYER. DARRAGH, BUCKLER, BEBENEK & ECK
114 South Main Street
Greensburg, PA 15601-3102
KORSAK & DeARMENT
Date:tjsl9u
,
By:
. Korsak, Esquire
33 N Queen Street
Yor , PA 17403
(717) 854-3175
1.0. No. 22233
r .. ~
.
"
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
~o. ~s..7194
No. ~S.71~S
CHRISTINE M. LAYMAN
,
.
VS.
THE HARVEST LIFE
INSURANCE COMPANY
CIVIL ACTION. LAW
TO: The Harvest Ufe Insurance Company
c/o John M. Noble, Esquire
Meyer, Darragh, Buckler, Bebenek & Eck
114 South Main Street
Greensburg, PA 15601-3102
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO TAKE AcnON
REQUIRED OF YOU IN THIS CASE. UNLESS YOU ACf WITHIN TEN (10)
DAYS OF THE DATE OF THIS NOTE, A JUDGMENT MAY BE ENTERED
AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR
PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS
NOTICE TO A 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.
D1STRICf COURT ADMINISTRATOR
CUMBERLAND COUNTY COURT HOUSE
CARLISLE, PENNSYLVANIA 17013
(717) 240.6200
February 16, 1996
Date:
By:
Josep orsak, Esquire
33 N Queen Street
Yor , PA 17403
(717) 854-3175
I.D. No. 22233
...,....._--...--.._ - ~~-'I'...></''''i .,.",. - ~_ _ I,." .
-""
.
..
-
.'
.
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on this date a true and correct
copy of the foregoing document, was served by first.class rnail, postage
prepaid, upon the following:
The Harvest Life Insurance Company
c/o John M. Noble, Esquire
Meyer, Darragh, Buckler, Bebenek & Eck
114 South Main Street
Greensburg, PA 15601-3102
KORSAK & DeARMENT
Date: ~IJ/l1t
By:
. Korsak, Esquire
th Queen Street
Y PA 17403
( 7) 854-3175
1.0. No. 22233
IH TBB COURT 01' COJOCOH l'LIAS 01' CUJlBIRLUID COUJITY, l'BIlHSYLVAHIA
CIVIL ACTIOH - LAW
TO ALL l'ARTIJlSa
You are hereby notified to plead
to the enolo.ed ADswer and Hew Hatter within
twenty (20) days of servioe hereof, or a
default judgment may be entered aqainst you.
I
." /'A, Ji-- 1---.'
JOHN M.' HOBLB, BSQUIRB
ATTOlUfBY POR DBPBHDANT,
HARVEST LIPB IHSURANCB COMPANY
,
.
CHRISTINE LAYMAN,
Plaintiff
VS.
THE HARVEST LIPE
INSURANCE COMPANY.
Defendant
/
/
..
(,.-/
No. 7194 of 1995
No. 7195 of 1995
AHSWER MID HO HATTER
TO lILAINTIPP' S COMPLAINT
Filed on behalf of:
Defendant, The Harvest
Life Insurance Company
COUNSEL OF RECORD FOR THIS
PARTY:
MEYER, DARRAGH, BUCKLER,
BEBENEK & ECK
114 SOUTH MAIN STREET
GREENSBURG, PA 15601
JOHN M. HOBLB, BSQUIRB
lIa. I.D. 136933
(412) 836-4840
III '1'B8 COvaT 01' COJDIOII l'LBA8 01' CUHBBRL>>ID COUIITY, l'BllHSYLVAHIA
CIVIL ACTION - LAW
CHRISTINE H. LAYMAN,
Plaintiff
No. 7194 of 1995
No. 7195 of 1995
VB.
THE HARVEST LIFE
INSURANCE COMPANY.
Defendant
AHSWBR J\HD Nn IlATTBR TO PLAINTIFP'S
CIVIL ACTION COMPLAINT
AND NOW comes the defendant, The Harvest Life Insurance
company, by and throuqh its attorney, John M. Noble, Esquire, and
files the within Answer and New Matter to Plaintiff's civil Action
Complaint and in support thereof avers as follows:
1. In reply to Paraqraph 1 of said civil Action Complaint,
after reasonable investiqation, the within defendant is without
sufficient information or knowledqe so as to form a belief as to
the truth of the averments contained therein which are therefore
denied pursuant to the Pennsylvania Rules of civil Procedure
pertaininq then and thereto.
2. In reply to paraqraph 2 of said civil Action complaint,
the alleqations contained therein are denied. Rather, The Harvest
Lifo Insurance Company is addressed at 6277 Sea Harbor Drive,
Orlando, Florida 32887.
3. In reply to Paraqraph 3 of said civil Action Complaint,
1
the allegations contained therein are denied and/or denied as
stated. While it is admitted that the policy of insurance attached
to plaintiff's civil Action complaint and marked as Exhibit "A" was
issued to Christine H. Layman as alleged, it is denied that
plaintiff is an insured under said policy of insurance under the
circumstances herein. Rather, based upon plaintiff's knowing,
willful, intentional and/or otherwise fraudulent misstatements
and/or failure to disclose accurate and/or truthful information
regarding her personal medical history within the application of
insurance, Christine H. Layman is not an insured under the terms of
the policy as all premium payments in the amount of $5,173.86
provided by plaintiff to defendant have been properly returned.
Paragraph 3 is further denied to the extent that it contains
conclusions of law to which no further responsive pleading is
required pursuant to the Pennsylvania Rules of Civil Procedure
pertaining then and thereto.
4. In reply to Paragraph 4 of said civil Action Complaint,
the allegations contained therein are admitted in part and denied
in part. It is admitted that plaintiff underwent a hysterectomy as
alleged, however, to the extent that it is inferred and/or
otherwise implied, it is specifically denied that plaintiff's
hysterectomy was solely related to the diagnosis of peritonitis
and/or that the within answering defendant, its agents, servants
and/or employees remain obligated to plaintiff under the terms of
the aforesaid policy of insurance for those reasons set forth more
fully above. Rather, it is believed and therefore averred that
2
plaintiff experienced a variety of medical illnesses, ailments,
conditions and/ or diseases ul timately resulting in plaintiff's
hysterectomy and that plaintiff's failure to truthfully and/or
other-",ise accurately disclose said pre-existing injuries, ailments,
diseases, conditions and/or otherwise voids the policy consistent
with the terms and provisions contained therein.
In the event that a more responsive pleading is required,
which is expressly denied, then it is believed and therefore
averred that plaintiff did not receive treatment in 1994 for
peritonitis and/or that peritonitis eventually resulted in
plaintiff's hysterectomy. Rather, it is believed and therefore
averred that plaintiff was admitted to York Hospital on August 18,
1994 as a result of dense pelvis adhesions, peritoneal inclusion
cyst and endometriosis along with a determination to "rule out"
peritonitis whereby plaintiff underwent an exploratory laparotomy,
lysis of adhesions and a total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
It is further believed and therefore averred that Christine M.
Layman underwent a laparoscopy on January 13, 1992 under the
treatment of reproductive endocrinologist Robert B. Filer, M.D.,
FACOG, at which time plaintiff was determined to have extensive
adhesions and endometriosis involving her left fallopian tube and
ovary which were lysed and ablated with an argon laser. It is
further believed and therefore averred that plaintiff previously
experienced problems with infertility and chronic severe pelvic
pain persisting through August of 1994 from August of 1989 at which
3
time she underwent a diagnostic laparoscopy, exploratory laparotomy
for lysis of adhesions and excision of a small fibroid again under
the care of Robert B. Filer, M.D., FACOG. It is believed and
therefore averred that plaintiff's pre-existing history of chronic
female genito-urinary system diseases, disorders and/or illness
eventually resulted in the noted hysterectomy.
5-6. In reply to Paragraphs 5 and 6 of said civil Action
complaint, the allegations contained therein are not denied,
however, to the extent that it is otherwise inferred and/or
implied, it is specifically denied that the within answering
defendant remains obligated to plaintiff for payment of said
medical treatments and/or services pursuant to the aforesaid policy
of insurance for those reasons set forth more fully herein.
7. Paragraph 7 of said civil Action Complaint is admitted in
part and denied in part. While it is admitted that bills have
been presented to the within answering defendant as alleged, it is
specifically denied that all pre-conditions for coverage have been
met for those reasons set forth more fully herein.
8. In reply to paragraph 8 of said Civil Action complaint,
the allegations contained therein are denied to the extent that it
infers and/or otherwise implies that the within answering defendant
has wrongly, wrongfully, improperly and/or otherwise unlawfully
refused payment to plaintiff for those reasons set forth more fully
herein.
WHEREFORE, The Harvest Life Insurance company denies liability
to plaintiff upon the cause of action alleged and demands judgment
4
'0'.-
"""";:':",',~'
"' "~,,,.
. .', ,'- ,-,~', ,-,,"";' ,.
in its favor with costs sustained.
By way of further Answer, defendant The Harvest Life Insurance
company asserts the following New Matter:
NB1fIlATTBR
9. As an affirmative defense to plaintiff's Civil Action
Complaint, The Harvest Life Insurance Company asserts those
applicable terms and provisions contained within the policy of
insurance issued to plaintiff and which policy is attached to
plaintiff's civil Action Complaint and marked as Exhibit "A".
10. within said Exhibit "A" to plaintiff's civil Action
complaint is a copy of plaintiff's application for benefits along
with plaintiff's signature dated July 14, 1993.
11. within said applicable for benefits, plaintiff Christine
M. Layman denied any prior medical diagnosis or treatment for any
disease or disorder of the "genito-urinary system (kidney, bladder,
reproductive organs, etc.) such as infection, bleeding, stones,
male or female disorders". Plaintiff Christine M. Layman
specifically denied and therefore fraudulently misstated any pre-
existing medical diagnosis or treatment for all of those inquiries
contained within the application from question 22 through 33. ~
oaae 2 of aoolication attached hereto and marked as Exhibit "A".
Plaintiff's policy of insurance was issued based upon the answers
to all of the questions contained on the application for insurance.
The medical information received regarding plaintiff contained
significant health history not disclosed on her original
application properly resulting in the contestability review and
5
6
rollowing recision or plaintiff's policy or insurance with a return
or all premiums paid on the policy in the amount of $5,173.86.
12. Based upon the provisions of the subject policy or
insurance, plaintirf's fraudulent misstatements, misrepresentations
and/or otherwise railure to provide truthful and/or accurate
inrormation regarding her pre-existing chronic medical illnesses
and/or diseases voids the policy of insurance and, accordingly,
plaintiff's premium payments in the amount of $5,173.86 have been
properly returned to plaintiff upon the termination of the policy.
13. By way of further affirmative defense, it is believed and
therefore averred that plaintiff was not treated in 1994 for
peritonitis which eventually resulted in a hysterectomy. Rather,
it is believed and therefore averred that plaintiff was admitted to
York Hospital on August 18, 1994 as a result of chronic medical
conditions including but not limited to dense pelvis adhesions,
peritoneal inclusion cyst and endometriosis along with a
determination to "rule out" peritonitis, plaintiff underwent an
exploratory laparotomy, lysis of adhesions and a total abdominal
hysterectomy and bilateral salpingo-oophorectomy.
WHEREFORE, The Harvest Life Insurance Company denies any and
all liability to plaintiff upon the cause of action alleged and
demands judqment in its favor with costs sustained.
Respecttully submitted,
MEYER, DARRAGH, BUCKLER,
BEBENEK , ECK
. ................,
,- I
. ,
By: / f' ---t., /'Y1
J6Wl-K. NOJlLE, ESQUIRE
Attorney/for Defendant
The Harvest Life
Insurance Company
f/
/
7
CA940406.A01
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.
EXHIBIT
I "A"
Page 2
.'
OATE: ),:2/-7 G.
JOHN M. ,~OBLE, ESQUIRE
VBRI~IID STATINIHT
I, Jolm K. 110):)1., I.quir., being the attorney for the
defendant herein, am duly authorized to make this verified
statement on their behalf as the verified statement of defendant
cannot be obtained in time for the filing of this pleading. I
hereby verify that the statements set forth in the within AHSWIR
AHD ... KATTIR are true and correct to the best of my knowledge,
information and belief.
I understand that false statements made herein are subject to
the penalties of 18 Pa. C.B.Section 4904, relating to unsworn
falsification to authorities.
c,-l---
1.../"/
CElTIrICAT. or BElVIC.
This is to certify that a true and correct copy of the within
AHB'" AXD ... HATTER has been mailed to all counsel of record by
forwardinq a copy of same, F~st Class U.S. Mail, postaqe prepaid,
this 1, ,) I day of '/uAw-y', 1996.
v -I=- ()
Joseph C.Korsak, Esquire
KORBAK , DeARHBHT
33 North Queen Street
York PA 17403
Attorney for Plaintiff
, .
r'\-:;'
( . L...-'
JOHN M. NOBLE, ESQUIRE
ATTORNEY FOR DEFENDANT
THE HARVEST LIFE INSURANCE
COMPANY
\....-.
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.....
Lt. \.Cl S
0 C;~ U
.
XM '1'B8 COURT 01' COIDCOM I'LBAB 01' CUKBBRLMlD COUNTY, PBHHSYLVAHIA
CIVIL ACTION - LAW
CHRISTINE LAYMAN,
Plaintiff
No. 7194 of 199~
No. 7195 of 1995
SUPI'LBMBNTAL VBRIrICATXON
vs.
THE HARVEST LIFE
INSURANCE COMPANY.
Defendant
Filed on behalf of:
Defendant, The Harvest
Life Insurance company
COUNSEL OF RECORD FOR THIS
PARTY:
MEYER, DARRAGH, BUCKLER,
BEBENEK & ECK
114 SOUTH MAIN STREET
GREENS BURG , PA 15601
JOHN K. NOBLB, ESQUIRB
Pa. I.D. #36933
(412) 836-4840
r.o.\ ".. \~'., >
"~o:,,,r:.:~
.."-_,,,,'t'''''''":'(4'\j'''~;'''''-'I'
, ,..-_-C,..,
FH-84554
VBRIrIID STATIKIHT
I, E /0./ Il~ ~ G ftJ h J'Yllf1, being the~ rr Co tI n.r,.R.. of THE
HARVEST LIPE INSURANCE COMPANY, am duly authorized to make this
Verified Statement on its behalf, and I hereby verify that the
statements set forth in the foregoing AHS.BR AND HEW HATTBR are
true and correct to the bast of my knowledge, information and
belief.
I understand that false statements made herein are subject to
the penalties of 18 Pa. S 4904, relating to unsworn falsification
to authorities.
~j/&~
"
Date:
U.u/'l~
CIRTlrICATB or 8BRVICB
This is to certify that a true and correct copy of the within
8UPPLBKBNTAL VBRlrlCATIOB has been mailed to all counsel of record
by forwarding
a copy of
:;.~'6</
same,
First Class U.S. Mail,
:::?~ 1996.
postage
.
prepaid, this
day of
Joseph c.Korsak, Esquire
KOR8JUt , DeARMENT
33 North Queen Street
York PA 17403
Attorney for Plaintiff
JOHN M~/ B E, E QUIRE
ATTO FOR DEFENDANT
THE VEST LIFE INSURANCE
COMPANY
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IN mE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
~o. 95.7194
No. 95-7195
CHRISTINE M. LAYMAN
:
VB.
mE HARVEST LIFE
INSURANCE COMPANY
.
.
CIVIL ACTION. LAW
REPLY TO NEW MATl'ER
9. Admitted that they are asserted; denied that the applicable terms and
conditions serve to bar Plaintiffs' claim under the policy.
10. Admitted.
11. Denied as stated. Defendant's alleged recision was irnproper and
illegal. Further Plaintiff made full disclosure of her condition to the Defendant's
agent, Steve O'Neil, at the time of application and was told by that agent that the
information need not be disclosed on the application. Plaintiff executed and
delivered a rnedical history disclosure relief from for Defendant's use to Defendant's
agent, Steve O'Neil.
12. Denied as stated. This is a conclusion of law for which no response is
required. Further, Plaintiff made full disclosure to Defendant's agent, Steve O'Neil.
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13. AdmJtted In part. It Is adrnltted that Plaintiff underwent the procedure
Indicated. However, Plaintiff rnade full disclosure In the application process and
should not be denied the benefit of coverage. Defendant's agent, Steve O'Neil, told
Plaintiff she need not disclose this Information because It was fertility related.
Respectfully Subrnitted,
KOR DeARMENT
Date: i t/N
By:
J s9ph C. Korsak, Esquire
orth Queen Street
ork, PA 17403
(717) 854-3175
1.0. No. 22233
,
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VERIFICATION
I, Christinc M, Layman, do hercby ccrtify that thc facts sct forth in the
forcgoing instrurncnt arc truc and corrcct to thc best of rny knowlcdgc, Information
and bclief.
Date:
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CERTIFICATE OF SERVICE
The undersigned hereby certifies that on this date a true and correct copy of
the foregoing docurnenl, was served by first-class rnall, postage prepaid, upon the
following:
The Harvest Life Insurance Company
c/o John M. Noble, Esquire
Meyer, Darragh, Buckler, Bebenek & Eck
114 South Main Street
Greensburg, PA 15601.3102
Date: 7/J I~t
KORSj & De~MENT
By. (~
A. eph C. Korsak, Esquire
J 3 North Queen Street
York, PA 17403
(717) 854-3175
I.D. No. 22233
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUN'IY,
PENNSYLVANIA
CHRISTINE M. LAYMAN : No. 95.7194 ./
No. 95.7195
va.
.
.
.
.
THE HARVEST LIFE
INSURANCE COMPANY
CIVIL ACTION. LAW
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on this date a true and correct
copy of Plaintifrs First Request for Production of Documents. First Set, was
served by first-class mail, postage prepaid, upon the following:
The Harvest Ufe Insurance Company
c/o John M. Noble, Esquire
Meyer, Darragh, Buckler, Bebenek & Eck
114 South Main Street
Greensburg, PA 15601-3102
Date: 08/16/96
By:
. Korsak, Esquire
N h Queen Street
o~ , PA 17403
(717) 854-3175
J.D. No. 22233
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CHRISTINE M. LAYMAN
No. 95.7194 .;
No. 95.7195
IN TIlE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
VI,
TIlE HARVEST LIFE
INSURANCE COMPANY
CIVIL ACTION. LAW
PRAECIPE TO SETTLE AND SATISFY
TO THE PROTHONOTARY:
Please rnark the above-captioned actions settled and satisfied of record.
KORSAK & DeARMENT
Date:
Novernber 21, 1996
By:
e C. Korsak, Esquire
orth Queen Street
York, PA 17403
(717) 854.3175
1.0. No. 22233
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