HomeMy WebLinkAbout95-07195
~
:3
~
QJ
J
.
-7
l
J
,
~
J
t.{)
0-
-
r
i
'{ti
;;f
','J
COMMONWEALTH OF PENNSYLVANIA
.
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
JUDICIAL OISTRICT
09-1-01
NOTICE OF APPEAL
FROM
DISTRICT JUSTICE JUDGMENT
COMMON PLEAS No, 95-7195 Civil Term
NOTICE OF APPEAL
Notice is gIven that tho appellant has fihnJ in the above Court 01 Common PltHI$ an illlIJUal horn the judUl11unt rcmlurclll.Jy tho District Justice
on thl! dale ami in the casu mentioned below.
~~...LL."T
..... DII.. MO. 0,. ....... 0.. ..,.
Charles A. Clement, Jr. 09-1-01
The Harveat Life Insurance Company
AQQ.." 0.. .........,n.
e".
Mechanicsburg, PA
.,,,,.
5
... CODI
4940 Ritter Road, Suite 105
II"'" .. IUDO"IH,
ll't "HI C..... ClIP ''''.n''',
Christine M. Layman
""'.........,,
12/5/95
The
fe Insurance Compsny
CLAIM MO.
CV19 442-95
L T 19
This hlock will be signed ONLY when this notation is ref.uired und~
R.C,P,J,P, No, 10088.
Tim Notice of AplJcal, when received by the District Justice, will olJCratc as
a SUPERSEDEAS 10 the judgment lor possession in this case.
ap/ w.... Claimant lsee Pa, R,C,P,J,P,
No, 001161 ill actioll be(ore District Justice, Ire
ST FILE A COMPLAINT witllin twentv 1201
elDVs after filillglris NOTICE o( APPEAL.
S,gn4Jwtl1 01 PtDrhrmor,Jtv Dr OrpUfY
PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE
ITlris section of form '0 be useel ONL Y wilen ap/Jellallt was DEFENDANT Isee Pa, R,C,P,J,P, No, 100/171 in iJCtioll before Oistrict Justice,
IF NO T USED. deraclr (rom co/IV o( notice o( a/'1leal to be servecl upon appelleel,
PRAECIPE: To Prothonotaey
Enterrule upon Christine M. Layman . appelleelsl. 10 fil a complain I in Ihis appeal
Niltn" 01 iJpp.llee(a/
95-7195 Ciuil Term ., .
lCommon Pleas No, I with", twenty 1201 days aftee service of r
RULE: To
Christine M. Layman
N.Jmc of .Jp~lI""fd
, appelleelsl
i
111 You are. notified that a rule is hereby enlered UI>on you to file a complaint inthiS appeal within twenty 1201 days aftee the date 01
service of this rule upon you by personal service or by certified or registered ma 1./
"
c /
, /
'" "'" """"' :".._,.,,"' .,,"," ,";,,;~. . '"'GM''' 0' '" "00. CC",' """,0 f"GAINST YOU,
131 The dote of seevice of this rule if service was hy mail is the date of mailing, J
Dlte: Dee. 18 .19...22
,
AOPC 312.90
.{HIHI f 111 i(}tl!- rflf,'II\/VlilliJlHYIIICJI'!t)j"I,H",
I (") i;
CrJ
.. ~~
co")
.- ::.;~
-
0.. C)~j
I~ co :~ ,;
- ..:.J.::
~ U I~~
I~ L ,_
Cl ~
l5 '"
en u
--61'
uo SOJ!dxo UO!5I!WWOJ ^w
,'!::JlJlOjoall'.1
.7prW It'M 1!'U!P'IIf! wOIIM OJoJDq 11!/3!}lO 10 iUnll'U61S
IUl1m' JO om,rJU6lS
'-61' ~OAVO SIHl
31'J 3110~3B 03Blll:JSBnS ONV (031'J1l1~~V) NllOMS
'OliUOlJ pall~ene ldp:JOJ S,JapUDS 'l!eW
(paJiJI5!6,lJ) (Ila!I!UiJJ) Art 0 o:J!^JiJS IDlloSlad All 0 '-OL' UD pan.ufJ(le SI!M iJl"lj a41 W04M
01 (S)Oalladde mil uodn Ir.addv 10 o:JqoN O^oqr. mil 6U1Aur.dwOJJl! IU!l?ldulOj e ill!:! O) rllnH 041 pOMas I UHU J041JnJ pue 0
'OUJJaq pmpcllD Id!aJ"J S,JDPUiJ'Ii '11CUI!PiJIaIS!6iJl) (IliJ!J!IH1J) ^CJ 0
un'
s. J.lIHJaS '"elu fpaJa15!6iJl) (Pil!J!IJaJ) Act 0 iJJ!^Jas ICUOUiHl Aq
un U!iJHHU palp.u6!siJIJ OJ!Unr IJp1S!O alll uodn .
.1J!^JaS IIHI05Jad All []-Ol'
(awful 'o.lWJtJde 0141 lIodn pue 'oliH,1l1 patpeuc 1l1!"Jal
o '-61' (O~!lUo'JOOjC"1
'oN scald 1I0lUlUO:l '1I!lJthlV JO aa!loN D41 JO Adoa I!
o
p'.'" Il"'ll"'""" J() mOM' AqOJ04 I :lIA'o'a1:1:1'o'
n: :JO ^~NnOO
\lIN\I^'^SNN~d ~O Hi '\l3MNOWWO~
(SBltOq BIQBOl/ddB ~~BI/:J '/BBddB }O BOIIOU BI/I BUll!! /J31:JV SA va (011 N31 N/H1/M a3?1:J 38 .iSmV BOIIUBS }O }oOJd sI1/11
1NI'o'1dWO::l 311:1 01 31ml CN'o' 1'o'3dd'o' :10 3::l110N :10 3::lIAl:l3S :10 :lOOl:ld
~ -
COMMONWEALTH OF PENNSYLVANIA
.' CO'UNlY OF: CUMBERLAND
Iolllg. Dol No.:
NOTICE OF JUDGMENT/TRANSCRIPT
PlAINTIFF: NAIl.... AlXlAE8a
rxAYMAN, CHRISTINE M.
555 E. BUTTER ROAD
YORK, PA 17402
L
..,
09-1-01
OJ NMle: Hon.
CHARLES A. CLEMENT, JR.
~: 1106 CARLISLE ROAD
CAMP HILL, PA
T~:n17) 761-4940 17011
ATTORNEY DEF PRIVATE
A-l. _
JOHN NOBLE . 0:i '{:..
MEYER DORRAGH
114 S. MAIN STREET
qREENSBURG, PA 15601
412 - Kj~- Litho
THIS IS TO NOTIFY YOU THAT:
Judgment:
[EJ- Judgment was entered for: (Name)
[EJ Judgment was entered against: (Name)
.J
VS.
DEFENDANT: NAIl.... ADOAEIIII
ITHE HARVEST LIFE INSURANCE CO. ..,
4940 RITTER ROAD
SUITE 105
l!IECHANISBURG, PA 17055 .J
Docket No,: CV-0000442-95
Date Flied: 10/31/95
DEFAULT .TUDGMENT PLTF
LAYMAN. CHRISTINE M.
THE HARVEST LIFE INSURANCE CO.
In the amount of $
6.728.45
(Date) 12/05/95
on:
o Damages will be assassed on:
(Date & Time)
o this case dismissed wtthout prejudice,
o Possession granted.
O Possession granted If money Judgment Is not
satisfied wtthln thirty days,
o Possession not granted,
o Levy Is stayed for _ days or 0 generally stayed,
o Objection to levy has been flied and hearing will be held:
I~" r-
TIme:
Amount of Judgment.
Judgment Costs
Interest on Judgment
Attorney Fees
L
TOTAL
$6,642.15
$86.30
$.00
$.00
$6,728.45
ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS OF
OF APPEAL WITH THE PROT NO I\RY I CL K OF C U
12-5-95 Date
I certify that this Is e true
12-5-95 Date
. District Justice
My commission expires first Monday of January, 1996,
SEAL
AOPC 315-95 .
. . .
~
\..,
~
-
r--
~
~
~(") ~
~~ r::? 5~
(") u~
I" ~ o~
~ ~ i*
V! f;:3 l'Qu.
F c ~
~ ~ G
~.., - ..
~ ~
. ( - \n
~'<)
~
~
r'\'-<
'-
~
~ ...
\~ ~
'0 '-
"'.' ~ Sil\
0~~,
-..,,-
-;.,"'">
""'" ...,-,~
1M HE COURT 01' CODOM lILIIAS 01' CtlHBBRLAND COUll'l'Y, lIBHHSYLVAHIA
CIVIL ACTION - LAW
CHRISTINE LAYMAN,
Plaintiff
VB.
No. 7195 of 1995
PROOI' 01' SERVICB AND RULB
TO I'lLB COMPLAINT
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
GREENSBURG, PA 15601
JOHN M. NOBLE, ESQUIRB
Pa. I.D. #36933
(412) 836-4840
PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT
IThis p,ool 01 service MUST BE FILED WITHIN TEN (101 DAYS AFTER Iillng /he notice 01 eppeal, Check applicable boxes)
COMMONWEALTH OF PENNSYLVANIA
WESTIIORELAND
COUNTY OF
;"
AFFIDAVIT: I hereby swear or affirm that I servell
[~]
a copy of the Notice o' Appeal, Common Pleas No.7-1-95_oW996on the District Justice designated thcluin nn
fdalt'o(serv;co} December 20.. 19~. 0 by personal service L~ hy (certified) (regislercd) mail, slmde"s
reccilH allaChc~ hcreto, an~SJPon the appellee, (nomw) ~~~J;Jne t.Jl.Yman . UIl
December 0, .19_0 hy personal service []c. hy (ccltified' (registered) mail, sender's receipt attached herelo.
~
and further that I served the Auh! to Fill' a C~'O"lainl
whom the Rule was addff!sscd on December ,
mail, sender's receipt allachcd hereto.
acco~ganYinu the above Notice of Appeal upon the appclh!cls) to
.19_. 0 by personal service ecJ hV (curtified) (refJisteredl
""../
SignOJrurc of a"/,mr
Tirlt. of O"'UJ'
My comnllssion cxpiws on
July 26.
,191996
L rb'....-"Sc:lI
BarOOrn n. Koz",. l':..'t:ry PlJ:ic
G~p.;.l$~{l,""_'SC'.:rx'Lf:a...:' .
My'::"."r;",,,,, Exp.'l:S.k''y~
titc:~:.;'OI'i~i~tJt:a ;rNc~llOS
S,gnaru'lI of P,orhotluriJ'Y 0' Depury
,
NOTICE OF APPEAL
.
COMMONWEALTH OF PENNSVLVANIA
COURT OF COMMON PLEAS
CIlMJIERLANIl COUNTY
JUDICIAL DISTRICT
09-1-01
FROM
DISTRICT JUSTICE JUDGMENT
CDMMONPLEASN.. 95-7195 Civil Term
NOTICE OF APPEAL
,
Notice is given that Iho appcllanl has filed in the above Court of Common Pleas an aplJCal from the judgment rendu,ed bV Ihe District Justice
on the date and in tho case mentioned bulow.
~o"-A;;,iiLL"""
M.... D'S'. "'D. 011 "'.... 0.. D.,.
Charlos A. Clement, Jr. 09-1-01
The Harveat Life laauraaca eo.pany
"00"...0" .......LL..""
4940 Rittar Road. Suite 105
C:'T"
Kacbanicaburg. PA
.,..,.
./ 170S5
.... C:OIll.
D..,. 0.. IUIll.....""
... 'M_ c".. 0" ''''. ",'"
Chriatina K. Layman
Tho Harweat
'1).0..........
CV19
L T 19
This block will Uc signed ONLY when this notation is requi,ed under Pa""';
~-;.
R.C,P.J.P, No, 10088,
This Notice of Appeal, when received by the District Justicu. will operate as
a SUPERSEDEAS to the judgment for possession in this case. /
442-95
..,
"Oltot.,U". 0" ".....LL.."'T Oil MIS .'TO"" Oil ......T
John K. NOb1~--Z;l--'
fa Insurance Company
12/5/95
CL..IM "'D.
1f~'J lIaflt was Claimant Iscc Pa, R.C,P.J,P,
No, 1001161 in action belorc District Justice, he
ST FILE A COMPLAINT within rwCllly 1201
"oys alter lilin9 his NOTICE of APPEAL,
./
. ~
PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE
ITlJis secrio" 01 lorm ro be "sc" ONL Y whc" oppcllanr was DEFENDANT Iscc Po. R.C.P.J,P. No. 100/11/ in action bclore Districr JlIStice,
IF NOT USED, detach from COllY of notice of 81Jpeal to be served upon appellee}.
PRAECIPE: To Prothonotary
Enter rule upon Christine M. LSY1lllln , aPlJcUeelsl. to lilc a complaint in Ihis .""eal
NiJme of iJPP~"ee(,' !I
lCommon Plea. No, 95-7195 Ciuil Term ) within twenty 120) day' alter .ervice 01 rule or~~fler ~'<lqudgment 01 non 1"05,
-' L.-- j
,.
RULE: To
Christine H. Layman
N.mo of appellee's}
Signa,uu, 'fIf ~ppell.nt 0' his,utomev 0' ilgenr
, .ppelleehl
/
,
.,
"
(1) You arc notified that a rule is hereby entered upon you 10 file a complaint in this appeal within twenty 1201 days alter the dale of
service of this rule upon you by personal service or bV certified or registered mall.
:321) II you do notlile a complaint within this time, a JUOGMENT OF NON PROS W"bl-BE ENTER~O A,..,f GAINST YOU.
I The date of .ervice of this rule if service was by mail i. Ihe date of mailing, J
Olte: Dec. 18 ,19..ll
AOPC 312-90
C(H,Hii ; Ii r
Z C!3? r.Cr. 9C!r.
~ Receipt for
.. Certified Mall
No In.urancI COV."gI ProvIded
..as 00 not us. for Intern.tlone' Mill
i ISH Rlver.,1
"'etrristine M. Layman
-
I s.
PO.5~'-el'dli'CodI
,. 8
...,...
~ $
! Ctlfblll'df..
Ie SIlltNl~f..
"""c"" 0eII\0Iry,..
".""nRlUOOISIIowIng
ro ~ I 0." o.w-Id
J A''''''flR<<NI~lOwttoItt.
Del.. IftCI Addl....... Addr...
rorAl Pot,. $
Ir_
Poslmlrk 01 Oil,
12/20/95
Z C!3? r.Cr. 9C!5
~ Receipt for r
Certified Mall :
_ No Insur.ne. COYII.ge Prov1dect
.c:L'.r:a Do not u.. for Int,rn'tlon.1 Mail
IS.. Rlv"..'
s.......,
Charles A. Clement Jr
!l'l'Srt-'t'ct Justice
PA $
C.""..d ,..
SPfNI ~ r..
Z!
...,treIM Otlldr., ,..
A,"tll fltelOOl s~
10 ~.. 0.11 0..-_
"I''''" RectlCl' Sho'lnl"Q 10 Whom,
0.... and AdGr.,,..', A6drn,
rO'Al~ $
,,-
POlltnf11r; 01 0.1,
12/20/95
--
----
, - ~~
..:r
..
-
-
:a ~~
lk N ~~
~ N
c...' u tn
bJ cD C-
O ~
II. '"
0 (jl
~ .. ..
.
IN TIlE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
CHRISTINE M. LAYMAN
No. 95.7194
No. 95.7195
V5.
TIlE HARVEST LIFE
INSURANCE COMPANY
CIVIL ACI'ION . LAW
NOTICE
YOU HAVE BEEN SUED IN COURT, IF YOU WISH TO DEFEND
AGAINST TIlE ClAIMS SET FORTH IN THE FOREGOING PAGES, YOU
MUST TAKE AcrION WITHIN TWENTY (20) DAYS AFfER TIllS
COMPLAINT AND NOTICE ARE SERVED BY ENTERING A WRITTEN
APPEARANCE, PERSONALLY OR BY AN ATIORNEY, AND flUNG IN
WRmNG WITH THE COURT YOUR DEFENSES OR OBJEcrIONS TO TIlE
ClAIMS SET FORTH AGAINST YOU, YOU ARE WARNED THAT IF YOU
FAIL TO DO SO, TIlE CASE MAY PROCEED WITIlOUT YOU, AND A I
JUDGMENT MAY BE ENTERED AGAINST YOU BY TIlE COURT WITIIOUT i
FURTIlER NOTICE TO YOU OR RELIEF REQUESTED BY TIlE PlAINTIFF.
YOU MAY LOSE MONEY OR PROPERTY OR OTIlER 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) 240-6200
A VISO
USTED HA SIDO DEMANDADO EN LA CORTE. SI USTED
DESEA DEFENDERSE DE LAS QUEJAS EXPUESTAS EN LAS PAGlNAS
SIGUIENTES. DEBE TOMAR ACCION DENTRO DE VEINTE (20) DIAS A
PARTIR DE LA FECHA EN QUE RECIBIO LA DEMANDA Y EL AVlSO.
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 DECIDlR EN SU CONTRA SIN
MAS A VlSO 0 NOTlFICACION 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 ATlENE 0 NO CONOCE UN ABOGADO, VAYA 0 LLAME A
LA OFICINA EN LA DlRECCION ESCRITA ABAJO PARA AVERIGUAR
DONDE PUDE OBTENER ASISTENCIA LEGAL.
LAWYER REFERRAL SERVICE
COURT ADMINISTRATOR
CUMBERLAND COUNTY COURT HOUSE
CARLISLE. PA 17013
(717) 240.6200
IN TIlE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
CHRISTINE M. LAYMAN
No. 95-7194
No. 95-7195
VS.
THE HARVEST LIFE
INSURANCE COMPANY
.
.
CIVIL ACfION . LAW
COMPLAINT
AND NOW, this 4th day of January, 1996, comes the Plaintiff, Christine M.
Layman, by and through her counsel, Joseph C. Korsak, Esquire. Korsak &
DeArment, and files the following Complaint:
1. The Plaintiff is an adult individual residing at 555 East Butter Road,
York, Pennsylvania 17402.
2. The Defendant is Harvest Life Insurance Company, 4940 Ritter Road,
Mechanicsburg, Pennsylvania 17055.
3. Plaintiff is an insured under a certain policy of insurance issued by
Defendant to Plaintifrs husband, Richard Layman, A copy of the agreement is
attached and marked Exhibit "A",
4. Plaintiff was treated in 1994 for peritonitis which eventually resulted In
a hysterectomy.
S. Plaintiff received the following treatment and services:
a. Apple Hill Surgical Associates
2S Monument Road
York, PA 17403
08/18/94
$1,335.00 (See Exhibit "8" Attached)
b. York 08/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 made 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 met.
8. Despite demand, the Defendant refuses to make payment pursuant to
the terms and conditions of the contract of insurance.
CA940406,AOl
Page 16
A.OUINlATAATIVE OFRCE
8m Sl!A HARBOR DRIVE
ORLANDO, FLORIDA:12117
.
.
~
HOME OFFICE
COWMBU8, OHIO
The Harvest Life Insurance Company
(An 0I\l0 6Iock CcIpcldllanI
MAJOR MEDICAL POUCY (FAMIlY)
POLICY NUltlltR EFFECTIVE DATE
lD26H51 01-19-1993
PRJHARY IIISURl:D - R1CHARO A LAYMAN
ADDRESS - 55S IlUnER ROAD
YORK! Pol
ZlPCOOE - lHOl
PREHIUlt
JNJTJAL - 1853.96
RENEWAL - 1833.96
TER" IN NOS - 03
AGE - 32
DEDUCTlBU AHOUNT - n.OOO.OO HAXlHUM LIFETlHE AHT - n.ooo.ooo.OO
COINSURANCE L1HiT - 5800.00 OPTIONAL MATERNITY BENEFIT - NO
MAXlMUH IOTAL 0 SABILITY PERJOO - 1 YEAR
WEEKLY 0 SABILlTY INOEHNITY - 550.00.
PRINCIPAL SUH ANO DEATH IlENEFIT - 510.0000
AGENT - ( 03781 I
STEPHEN O'NEILL
OAT AGE 55. UENEFIT REUUCES TO 15.000;
AT AGE 60. BENEFIT REDUCES TO 52.500;
AT AGE 65. BENEFIT 15 TERHlNATEO.
FURH - HHFPB/88PA
HOW TO FILE A CLAIM
In ca.. nr Loss ror whicl1 claim i.lo be made. notiry in wOlin,:
The Harvest IJrelnslll'lllCC Company
AIIn: Calms J)qlt,
6271 Sea Harbor Driw:
Otlando, ADriela 3281'7
Be sure 10 'tale:
1-) Your complete policy number.
Ibl Your present address;
(c) Dale or Injury or Sickness and nalU~ or Loss;
(d) Name and address or a"endln, physician;
(e) Name II1d add~ss or Hospilal. ir you were confined.
Wrilten nOlIee or claim must be aMn within lhe lime period 'Lltalln Ihls policy aller the oa:umnce or commencanent
of any Loss co..red by Ihi. policy.
CA940406,AOl
Page 1
!Mj
. ,.~.
__nun IHIU1WlCl1
....1. __APPl.ICATIONTO: _.__clIl.....u..a_
1ftI un au tIAMOII OIlMVI
OIU.MOO.'" JlII7
e NIW.......... D CONVIRIION C ADMI MUMMeI
N! 2755612
'~ll-"AQI t
1)'''_oI_''-''--CWl.-',71 / I . ... / ~i':~i:.n I:
'-.. '. . , ~'. ' . . , . . , , "7t1
~""}'C r2 , .- - . . . R..L , , . . , .. -. 1",,::",,1 t.,......
. . . . . , , , , , IG c) ',,,- II... -
l<Jly.Lk.. . . n. ' I~" "~r""""""""
, . . . , . . . , . , . , ., I, 7o~,();l. ~..
I. 0wMr CLaM. PI,., .......1 I A..........' .. 0wMn lealllecum, Hu......
. . , . . , . . , , . . . , . . . , . , , , , . , , , ~~'I .S"l&,ii;..,i~-o
10. ,...,..one.......... ........ DY,. t A.u..... 0 y" _.-
.... ::=:- .... ::.':" ..........
Ho...: Cod. . CNo _ Cof. . CNo
11. LI" "-AN HlAL'" PLAN
~W"'" - t......... PalIC6M I'" -
.... , OIduc:1lbll ,.... .... - - .... - -
....'" . .l<'I ~ ..1
...lter.Pte"'....nl ..... Pl,'" ""
o 0 Ac:ctden... Dull
C 0 Watwf of "..."'"
o DGuarMIMClIfl..Optioft
C C '...w, IMYI'IIa "kit,
C o ~,.,.'.lNuttftU IIl1d..
C O"*mofCl,,,Vat\Ie
C C ov.o. u OPTIOH~ UATlIlHl1't DlHlFlT
CY.. 0..... Do.'1fte "'" MOAIN, ""....,. tOfU aNI .....101 f,OM CY..
I, Auto"'atlC ,~'"" Loa" ,I...,.en CNo CH. III comp'''....ICMd6l...oI t'O\I",,'qltftOftWYlftCOlft" COo
12."'''III(l&ry A/Ylln ~,.'o/Y- ...,,:~~ L J._
13 COftUl'lQ-.t hftlftCIl" 'l',..,.,.7L. R"'hOft~
'4 ~ OeptJftOWlII kt1ec11 ...1Ow WI" be ilftWHd ON)' U,,"I ,....tty Po&tc... .pplled lor lft Q.,..I.. '" Md only.1 ace.,IN"'''' eom,.ny.
SpoU'MICJ\lId,.,..la M '"""'"' ""'t. Dalto' -.. H' WI CI'lIId,.n 10 bl ,n,..red _.. 011101 -.. .. WI
..... 1"1"
14...., ,J,...., ,i "'- ,-,/: I.....,.~ .J
,. ...
A...:. A6"",.' I "~I" I'r " ..,
R.... , ~,....,... pjf ~ ,-
"" S
A.. . /... .. 'W 1_...... :y . .;;:?-
If 1....1ty CO"I''''';:fIa' Iny ""Ill"' lI..n ollllltad' o VIS CNa 11-,.,4. "."'. ,nd '''IOn
,.."'......~....I.....,,'_ .,...... 1,.,'.TIf'"OCClIPII" 1-"-
".lM~ 'S</~ IT..,. fOf"'.,(lIIplOy.,. RE I v..,.
....... -1 Add'''' I
".LJteI~6ft'."""'AlI6ftt - II. ......1'*'1U'CI6ft 3;r[(.~~AMouftttI .........
"-..- VI.I..... .... .-.. A,D.AIIlOUfII CoIIl...... .. H . ....101..... AD.AIftounl
~ ":'NU
11. Yfil C",,.nt .HtlCallon C........ ot "",aa Iny '.I"~ III.. ~ Of 'lWIUlly ....n' OVII .,rHO
"..,.....11... 0MaI1, CInCI.... CDfftIlJP,.... paUcy """"*I.nd COfIlIlIet. ~d CCIfI'IMhtDfl'onM.
20. YMIuI luMlnallOflll"",,"' OVlS ?<<NO 21.'''''''tttIOfy .... "MM......",. .... Cav.. 01 OMI"
-
1l.......Dblalnf."'nJftlatOtY. ,.-
("IIl'Mil "'0""
Add,... ........
0.11 Idled....... ...-
__... .....we.. _ llrlloIMt,....
o AQeliII DtlWitIy
UA",."A
IllI2I
CA940406,AOl
'M11-,,","1
.""........ ___.............. _.-;...... fIIIC"",...,..........-. '"...
..... My' pM'IOft prv90Md tot ........
n8Mfl~~Of",,''''10f'''r'''''''
OI_tofd.,olI- Y.. No
. """'.\Ort..,....CIuhQ..WOftCH...........)IWCIftIlT.. ./
Ulhll\a,emph""""'l:NOfld'll"' ................ DP
II OmHtory.,....~~.arI....wIIIM.-llUdt.. J
frliOfttllOall".....,.,...........""",..,rt ......... D~
c. o.enlnotllYl..... (~YI. ....... ....... 1_. ...
bladdlr. Ile.1 aueft .. .....r. ..,,,...... ......,,,..,.. 0.1
bllttdItlO' .0.... ....... .....0........ '0' ~
II ~..,..l....(btllfl.~etcl-"..~..,....
Iftl. "ll,..y. c.ft,ul~'ft'. ",..u.1 .r ..".ou. dl"
Dr6enI1................................ Dp"
.. t.Ir.ttc~., M'd....... .,....1......... tMIMI. totnt......
_I weft.. '*' Of.. proNefN. ...."""' ........CIUI J
or....pu.......~ ..... ........ ......... .0... 0,.
I. QenIIO-Uf~'~~Cl6dMr.IlI.....NJlfOduC..........
etC.1 tyCt'I.. .................. Of tlft\l&e....
Ofdert' ................................ Dr;
o QI-'uW """"' t"""""'. 1NftC't'u. ........."""".....
Ite.1 aue" II dl."'''. af .b"Of.,1 .,.w'" ,f
~1On' ..............................
n Ih.'bMndlagnoledby.pfl,........-.AcctU'NlItlMIUN
DlhoWICy ~ ("AID$"). AIda....... CclMpIu rARC'1
OIbel1ft...II1IIorAJOS1......................
111 blf"Pod poIIIMIDfanlibodt1tolhl AlDS~" T.etI
Lr"fIPhOUopc. TfPOUI; HTLY.I.) "",,' .............
~ r... -....n fNdiullr...... teN....... of ""101 --.CIftC*.
C)'II Of 1urNW....... --. twrNI fit IlUn ....., . . . .
11. r....__DdCJOaflll'..'''Wft,,.,,....,ofpiKII.plfdly' -
".u1I.~'__._._. .-.-- --
l' r..'hlddll..e,..IIc...."'spDf'dedOlrt'woll.,WV...IIutI..'
a~
0,6
aII'
~1
0'
al..,......IftIft1Uf_~fof"'YI'YOIIIQMIt' .....
HI. "" PIlton ~ for .,."".... ...,. 'lOW know IIld
-,
ftWIItWI........'......
.. twlI tift o&M'.""'" ., InfWY ........, ......... .,
......-tOf Md lIlY....... .....W'...,.. ....ay.lJCG.
IlborIttafy....' ... ...... ...... .... .......
It. HId ....." Of ~.IkIfI. bIIft UNMr .....,...... Of .,.t.
"*"-,...,....... .1tItdca1iOft Of"""" 1IeIft.......
afCGft"""" ............................
Co ..... 1ItMbl1., ........ WoI1Untft" COmpen....... Of
.................................-.y.....,...........
....., .... .... ... ......... .... .......
.,..........~.dNI................" .........
.. HldcMIIl*ft, "*"*'''lrMIh. oourth.~.
~'.............................
.. e..nfNdlclllyd.............,..,..,.uw""""......
.,...,.....,...,.,...,....................... .
31. AIty__..........~....... poI\IlONd.......
on.r.d OI.,oted Of" au~ 01,...,....' ......
32. Mt put. ..-......pedId:
.. A""'*'ac.......n.....OfcteW......"..........
It, HuardOuI~......~.......' . .. . ..
33_ II...... -
.. /tIty_DI'PfnenlIC8l'I'~-....Oft.oI,.'I'*'CJ' ......
b, Now~...........................
,. lOa
0-"
a.d'
a <If
~~
ad
ad
a<t'
aid'
a....
a~
09'
)Ii ,......., docIO ~ D None
~ . C. w4A- ~
OIttlMlCOftll,lfllld :lA,... 1'1'''
........Md.-..IU.. ~.,IJy - F(J - #J f.~"'''
)I. 011.... tar ANY "Y.-....... .......... D 1fVoUIh:M.... Of canes 101 ""*" 'to" "'.. canaulled. physlCWt Of
pnclltiOMf 1ft _....'hII.,..,. (11II* "",lM~);
- .....---
-
No.
-..
..-
0.. ...... 1M! ...........--.
1kIYt. ........ .......,.
-
DNII.. '" ___..................
.....,.~........... ......
31. s _1..53 ~ haoIbeOft....latheaoent.-..fIIId~"'umil..l.not...uft\Cllltrotlll.CO""..'r.
I lot WI' f\e'M rudatld unctmW'lcll........W.",efttl Md........ TOIM _..ol",yIOl'OII'1 ,-'"te.,........ ~...IINeIftdC~1ftd
eOlfeetly fCOfcllcd. and I lor WI) III\<' "ad the No&c. to ~ -'KIt lIfIC.fuOIs Ifle ............ COIl___ ""*' Ncnc:e M1t.. Medal
InloflftlllOf' IknMt IJIIeIoIUN HoIICO.
An, PropoMd lMured.nd" 0wMt'.. odIef 111M lhe Pf'ooCtWd tfll&ftd, ~ tl\al.1 aUlla'lllnb lII'l4I.......,.contIInt4.. PwtOM ~
Wllh IhCllO lftIdI,n '*' 1.0 ... 10 Ill. bell of M or ....10' 1MIf1 'f\OWktd9t and _MI. ful. comoll" ard I,. .. ""I'" and .,.CDfftdY'econMd""
...cw...,....... toIIOWS: 11.1 TfIIS appkatIOfI.. and ",ypollcy Of"*_.... "'III eonal,I""...... UItItr.d of IntufaN:8:1N1 IN CompuIy
"",Ino! M bouN 1ft InY'Wfr't"" .ny."....."...."......... IntoffMttOnIllMeOlQhCftb,Of to.,..IIfttOf CMtlW.....on.....r.............UfM
bl 1ft "'.11"9 .1Id MltImI'" 10 lho ~ .lltI HofM Ofkl and mid.' part 01 such cantflCt 0I\fy. CO",pany OffiC<< ruy MIU. MOdIfy 01
dOld\lfQOeontrlCt.Of......'"'of...~rr(.'i9hIlDl,...~.rdlMn...,In""""', 12.1 1M 1ft......1Q I'lefny.lIllllMl_..... not be
eonlld"'oct In tore. Uflbl. poley "'.. hI..ebMnluUld..,'" CofI'I""",.tId IIId poe.cy ..._1IIlIy fKefNd'''' acuotld trot..,. o..w IIICItI'le I.,..
P'WItl"""' paod, III dun"", IhI VOOd hNlthol an" fInlpaMcll 1tlIu,.... " I_lull NIl rd"'IU"'.' pi" '"lCt'IoIIICIlo.n IUUIoNCd evenl OIN CMlPM'
...... Ift,,.,~ I"IUfeCIra"'QOOdheaMandlMeondlloOftlt'lCIIpton"'tOfm.11KNd ...IWftdto"C)wMf.lhilnlMllltplyof"CoW\JIIIIY
ilia' be" &!MId In IUdl rftOIfII 13 I Poley ......rtNP.. .,..........uatyto p,apoMd IllMtNlf.,. PftOI'..... of 0wMt, uMlU.IMftdad......
byOWl'lClf,
llUthO"" .ny phrtici.".fIOIPI....diftIC. 0I01Nf IMdIcaIr niIaIedtKMr. .."""'" compony,... MldlUJ If'lIonMIIon lkuMU, Dl....orvlfMDlion
Of pctIonlO QMthclHIAftILII.I.,.",.tICI Cofft9a...,.Of...""".....".n'.fIld IIllfl1onMlIOn.."',...Nnc.tofMOI'''''.....,..... .."."..,..01
ffty IMIIIy tar .tlodI CCMnOI I' propoMd. A DhOIooraptlic COPY 01 tIwt MANMtI.llOn aNd be .. ,.id II the ongtnaI. 11110 IC'IIOWI"" ,..." of "'.
;:~:-'-'~;'''' 7~"g .~~ .
_~ .. .//. . .L'
1~1,lhlll"...t""'.ndKC"'.,...'_.....on.,.lCIfIkalloftlM V./. :/I1~T' .
INonNIbOl'itJUllCllted...,..fItoClOIlNII........JJdIOIC).Mf. ToU'll SOOuMIII to lUtad'
bell 0' nlr ,nowItdga. "'.. k>>f n don )D1SOII no! d'ltnlJl at
~;;t;(l~~ BL7~L__
AlJIftt . ~Ho.
Ownaf I" __ """ f't0ll0lld"""'"
II' buut\lIIU......ce....... 01 oaGM MIl ""'" of ""'I
.
Page 2
I
ADMINISTRATIVE OFFICE
6277 SEA HARBOR DRIVE
ORLANDO, FLORIDA 32887
,
I
}U~{ \
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 LIMITED AND
PROVIDED. THIS POLICY TERMINATES ON THE POLICY ANNIVERSARY FOLLOWING ATTAINMENT OF
AN AGE QUALIFYING YOU TO BE ELIGIBLE FOR MEDICARE, THIS POLICY IS NON.PARTICIPATING.
In this policy the Insured is also called "you" or "your." The Harvest Life Insuronce Company is called "us,''''we,'' "our"
or "the Company," The "Definitions" section defines other words and tenns used in this policy.
In consideration of your payment of premiums for this policy, the Company insures you and all Insured Persons against
loss caused by Injury or Sickness as herein limited and provided. Coveroge is provided subject to the tenns ofthis policy,
The amount of the first premium and the Effective Date of your policy are shown in the Schedule of Policy Infonnation.
This policy is a legal controct between you and the Company. 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 3D-day period, if you are dissatisfied
with the policy, it may be returned to the Company at its Home Office, The Harvest Life Insuronce Company, 62TI Sea
Harbor Drive, Orlando, Florida 32887; to any stale office of the Company, or 10 the agent it was purchased from. Im-
mediately upon such return this policy shall be void from the beginning and any premium paid will be refunded,
Ql'ALlFIED RIGHT OF RE."IEWAL
You have the right to renew this policy, forconsecuti,'e terms, by the payment of the required premium before the end of each
Grace Period. You have the right to renew this policy regardless of changes in your physical. mental or health condilions. Your
right 10 renew this policy is subject only to the Company's right 10 non-renew this policy on the next premium due date following
the date the Company gives wrillen notice ofits intent notlO renew all policies issued on this fonn in your slate of residence. The
Company will give you at least 60 days advance notice in writing prior to non-renewal of this policy. Any non-renewal shall be
without prejudice to any claim originating while this policy is in force.
PREMruM AGREEMENT
Pn:mi~ms for this policy will inc~ase peri~icall~ due .to the increase in your age, Upon attainment of an age requiring
a rote. Inc~ase, the renewal p!'lmlum fo~ thiS pohcy Will be the. renew~1 premium then in effect for your attained age.
Premium Increases du~ to a~talned age will ~ake effect on the p?hcy anniversary following your birthday. Premiums may
~Iso be changed for. this pohcy on any premIUm due date, proVided premiums for all policies issued on this fonn number
In your stat~ of.resld~~ce arc also chan.ged, For any nonscheduled pre~ium change, we will give you alleast 30 days
adv.ance nOllc~ m wnllng o~ such pn;mlum chan,ge, Each renewal. premium for this policy will be due atlhe end of the
penod fo~ which the precedmg premium was paid. Renewal premiums shall be payable by you or on your behalf at our
Home Olfice.
IMPORTANT NOTICE
Please read the copy ofthe application allached to this policy. Omissions or misstatements in the application could cause an
otherwise valid claim to be denied. Carefully check the application and write to The Harvest Life Insurance Company, 6277
Sea Harbor Drive, Orlando, Florida 32887. within 10 days of the receipt of this policy if any information shown on il is nol
correcl and complete or if any past medical history is left OUI of the application. This application is part of the policy and this
policy was issued on the basis that the answers to all 'lue5tions and the information shown on the application are correct and
complete to the best of the applicant's knowledge and belief.
Fonn MMFP-8/88 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, MentallUness, NerVous Disorders and
Drug Dependency Benefit......,..................,........ 7
E, Extended Care Facility and Skilled
Nursing Facility Benefit.........................,......,...... 7
F, Total Disability Income Benefit.. ....,..,..........,...., 7
Q, Accidental Death
and Dismemberment Benefit..,....,............,........, 8
." Page
Conversion ProvISion....,..,..,.................,..,.., 9
Definition ,.....,......................,........,..,.......... ...........2:5
Exclusions ......................................,..,.. ................... 6
How to File a Claim ........................,..,......::::::::::::::'i2
Policy Provisions.....................,....,....,..,...........,.. 10-1 I
Premium Agreement........................................,......, I
Renewal Agreement,...........................,..........,........, I
Schedule of Policy Information.................,..,.........,12
Table of Contents....................................,................ 2
Termination of Coverage,........................,..,......"......9
DEFINITIONS
Ambulatory Surgical Center
means a facility not located upon the premises of 0 hospital which provides outpatient surgical treatment, Ambulatory
Surgical Center docs not include individual or group prnctice offices of private physicians or dentists unless such offices
have a distinct port used solely for outpatient surgical treatment on a regular and organized basis, A facility existing for
the primary purpose of performing thernpeutic abonions sholl not be construed to be an Ambulatory Surgical Center, Out-
patient surgical treatment means surgical treatment to patients who do not require hospitalization, but who require constant
medical supervision following the surgical procedure performed,
Coinsurance UmU
means the maximum amount of Eligible Medical Expenses, exclusive of the Deductible, you will be required to
pay in anyone calendar year, This Coinsurance Limit is shown in the Schedule of Policy Information,
Coinsurance Share
means the Eligible Medical Expenses incurred by an Insured Person in each calendar year for which that Insured
Person is required to pay. c.~clusive of the Deductible,
Common Accident Deductible
If twO or more Insured Persons are injured in the same accident, only one Deductible will apply to withe Eligible
Medical Expenses they incur in the calendar year in which the Injury occurred as a result of that accident,
ComplicatIon of Pregnancy
A Complication of Pregnancy is a Sickness under this policy.
A Complication of Pregnancy means:
(a) conditions requiring medical treatment prior orsubsequentto the termination of pregnancy whose diagnoses
are distinct ~r?m pregna~cy but, which are adver~ely af~ected by P!egna~cy or caused by pregnancy, such as
acute nephnlls, ne~hr05lS, cardlOc de,co~pensat..on. missed ~borllon. ~~sease of the ~'ascular, hemopoieatic,
nervous. or endocnne systems, and Similar medical and surgical condlllons of comparable severitv: but will
not include false labor. occasional spOiling, physician prescribed rest during the period of p'regnancv,
morning sickness and similar conditions associated with the management of a difficult pregnancv not
constituting 0 classifiably distinct complication of pregnancy: and .
(b) hyperemesis gravidarum and pre-eclampsia requiring hospital confinement, ectopic pregnancv which is
terminated, and spontaneous termination of pregnancy which occurs during a period of gestation in which a
viable birth is not possible: and
(c) conditions requiring medical treatment after the termination of pregnancv whose diagnoses are distinct from
pregnancy but which are adversely affected by pregnancy or caused by pregnancy.
A Complication of Pregnancy docs not mean:
I. false labor;
2, occasional spOiling;
3, Physician prescribed rest;
4, morning sickness;
5, .other condilions connected with a difficult pregnancy nOI being a separate scientifically c1assilied
Complication of PregnancY'L
\-
f)
()
Deducllble
means the amount of Ellalble Medical Expenses that must be Incurred by an Insured Person In each calendar year
before benefits will be plyable. We do not pay this amount. The Deductible Is shown In the Schedule of Policy
Information.
Deducllble Carried Over Afler September 30
Any Ellaible Medical Expenses that are both:
I. Incurred after September 30; and
2, applied to an Insured Person's Deductible for that year but not sufficient to satisfy that year's Deductible will
also be applied to that person's Deductible for the next calendar year, If the Deductible was satisfied In the
previous year, no expenses will be carried over to satisfy the next year's Deductible.
Deducllble Maximum
A maximum of three Deductibles, for all Insured Persons, is payable In anyone calendar year,
Ellalble Medical Expenses
means those charges for medical services and supplies that are listed in the Benefit Section and are:
I. thc 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 Care Faclllly and Skilled Nurslnll Facility
means an institution which:
I. is operated pursuant to law;
2, is primarily engaged in providing, in addition to room and board accommodations, skilled nursing care on a
24.hour basis by or under the supervision 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 ~t;
2, a home or facility for the aged or a facility primarily used for drug addiction or alcoholism: or
3, a home or facility primarily used for cwtodial or educational care,
Hospital
means an institution which:
I. operates persuantto 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 institution which is primarily used as:
I. convalescent homes or convalescent, rest, or nursing facilities:
2, facilities primarily affording custodial or educational care: or
3, facilities for the aged,
Form MMFNl/88 PA
Page 3
.-.-'
Injury , .
means accidental bodily Injury which:
I. occurs while this policy Is In force:
2, causes Loss while this policy is In force; and
3, does not result from disease or bodily Infirmity.
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 specifically 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,
Lifetime Ma:dmum Amount
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 S~ctions,
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 substitutcs thereor',
Mental \IIness and Nervous Disorders
Mental, nervous or emotional disorders ",ithout 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.
Pre-alstlng 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 so named in the application for insurance for Ihis policy,
Usual and Customury Churge
means the average charge made for the same service or supply in the same geographiC:lI area bv the same tvpe 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 poticy is in force,
'\
,
F'
,
,-
,
T olal DlsabWly
mea/15 thaI you an: 101lllly di~bled due to either Injury or Sickness, and:
I, an: unable 10 pcrfonn all substanlial and material duties of your n:gular occupation:
2. an: not pinfully employed in any other occupalion for wage or profit because of such T ollll Disability; and
3. an: under the n:gular can: of a Physician because of such Total Disability,
PRE.EXISTING CONDITIONS LIMITATION
During the fantl2 months this pollcy is in force. it docs nol cover loss caused by a Sickness or physical condition diagnosed by a
physician prior 10 the Effective Date. and for which an Insun:d Person sought or received consultation, advice or treatment by a
Physician within 12 months prior to the Effective Date, Also not covered is loss which is excluded by name or spcci/ic description,
BENEFIT SECTION
PARr 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
E1iaible Medical Expenses listed below, we will pay benefits to you, after the deduclible has been satisfied. Once
the Deductible has been salisfied, we will pay 80llJo of the Insured Person's Eligible Medical Expenses until the
Coinsurance Share has equalled Ihe Coinsurance Limil for Ihat Insured Person in Ihal calendar year. After the
Coinsurance Share has equalled the Coinsurance limit for that Insured Person in that calendar year, we will pay
100"10 of the Eliaible Medical Expenses incurred during that calendar year for that Insured Person, but not 10 exceed
the Lifetime Maximum Amount shown in the Schedule of Policy Information,
The Deductible and the Coinsurance Share requirements will be applied only once to each Insured Person in any
one calendar year,
EJi&ible Medlc:al Expenses
J. Hospilal room, board, and general nursing services. nOlto e.xceed the Hospital's slllndard semi-private room rate;
2, In lieu of'l above, Intensive Care Unit of a Hospital, not to exceed three times the Hospital's standard semi-
private room rate;
3, Miscellaneous 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, anesthesiologist; and
b, radiologist;
6, Physician's treatment, other than surgery, limited 10 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 fim Physician who initially proposed
the surgical operation;
8, Private duty nursing care by a registered graduate nurse, other than the Insured Person or a member of the
Insured Person's immediate family, while an Insured Person is Hospital confined;
9, Charges for prOfessional ambulance service to and from a Hospilal or Ambulatory Surgical Center wilhin a
ISO-mile radius of such facililies;
10. Charges for the treatment for Injury to sound, natural teeth; and
11. Charges for the medical care, treatment, services, and supplies listed below:
a. x-ray examinations, microscopic and laboratory tests (including pre.admission Hospital tests given to an
Insured Person in a Hospital or on an outpatient basis prior 10 Hospital admission), and other diagnostic
services;
b, treatment by chemotherapy, x-ray, radium or other radioactive substances;
c. casts. splints, braces, crutches. and surgical dressings;
d, anificial limbs and eyes;
c. hean pacemaker;
1', renllll (not to exceed the purchase price) of the followmg: 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 morc than one category, the expense will be considered
only once for benefits,
.'!...,.......
PART B-EMERGENCY OUTPATIENT ACCIDENT BENEFIT
We will pay an Emergency Outpatient Accident Benefit if; .
I. an Insu.red PerliOn has II loss due to Injury while this policy is in force; and
2. the Insured Person is treated in a Physician's office, clinic, or Hospital as an outpatient.
We will pay 80",0 of the expenses actually incurred for:
1. Charges for professional ambulance service to and from a Hospital or Ambulatory Surgical Center within a
ISO-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. x-ray examinations and laboratory tests;
b, anesthetics and their administration;
c. operating or emergency room;
d. casts, splints, and surgical dressings;
Co drugs and medications administered in a Physician's office, clinic, or Hospital,
The Deductible requirement will not apply to this Benefit,
PART C-MASTECIOMY; PROSTHETIC DEVICES BENEFIT
We will pay benefits for prosthetic devices to maintain or replace body pans 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 the medical necessit} or desirability of a proposed
course of rehabilitative treatment, The cost and fitting of a prosthetic device following a mastectomy is included
under this benefit,
Exclusions From Coverage Under I':lrt A, I':lrt B & Part C
This policy does not cover charges:
I, for treatment of an Injury or Sickness due to war or an act of war;
2, for treatment of intentionally self.innicted Injury or attempted suicide;
3, for treatment of an Injury or Sickness to the Co'(tent benefits are payable under any Worker's Compensation
or Occupational Disease law;
4, for dentures, dentistry, dental surgery, or dental x-rays, except for the treatment for Injury to sound, natural teeth;
S, for eyeglasses, contact lenses, hearing aids, or for the e.'Illl11ination for crescribing or fitting them;
6, for services which the Insured Person is not, in the absence of insurance, required 10 pay;
7, for cosmetic care, treatment, or surgery, unless it is due to an accidemallnjury or 10 conect birth abnonnalilies or
defects:
8, for nonnal pregnancy and childbirth (unless the Malemity Benefit Rider is elected);
9, for physical examinalions thaI are nOI necessary for the diagnosis and treatment of an Injury or Sickness:
10, for drugs and medicines other than those 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 of Mentalll!ness, Nervous Disorders (without demonslrable organic origin) or Drug Dependency excepl
as provided in Benefit Section Pan 0;
14, for treaunent of an Injury or Sickness 10 Ihe extenl benefits are payable under automobile insurance first pany benefits,
Catastrophic loss benefits paid by the Catastrophic loss Trusl Fund and any workers compensalion benefits;
I S, for Pre-existing condilions during Ihe first 12 months:
16, for any loss sustained or contracted in consequence of any Insured Person being legally intoxicated or under the
influence of any narcotic unless administered on the advice of a Physician.
,
Pa e 6
.-
r....
PAIR' D-MENTAL ILLNESS, NERVOUS DISORDERS ~ND DRUG DEPENDENCY BENEFIT
If an Insured Penon has a Loss due to mental or nervous disorders or drull dependency we will pay 50.,. of the
expenses actually Incurred for:
I. Hospilal treatment; and
2, Physician'! visits, not to exceed a maximum of 530 per visit. limited to one visit per day.
1bcsc benefits will not be paid until afler the Deductible has been satisfied, The Part D Lifetime Maximum Amollllt
payable for any Insured ~rson will be 55,000.
PAIn' E-EXTENDED CARE FACILITY AND SKILLED NURSING FACILITY BENEFIT
If an Insured ~rson 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 Nursing Facility, benefits will be paid provided:
I. the Insured ~rson was confined In a Hospital before his or her Extended Care Facility or Skilled Nurslnll
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 ~rson's Physician;
3. the Insured ~rson's Extended Care Facility or Skilled Nursing Facility confinement begins within 30 days after
discharge from the Hospital;
4. the Hospital confinement was an Eligible Medical Expense under Ihis policy; and
5. the Extended Care Facility or Skilled Nursing Facility conlinement 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,lhe expenses the Insured Person actually incurs,
The total Part E benefit payable shall not exceed 8ll",l, ofthe amountlhe Insured Person was charged for hospital room. board
(not exceeding the Hospital's standard semi-private room rale). and general nursing services, during his or her Hospital stay
before being transfermlto the Extended Care Facility or Skilled Nursing Faciltiy, These benefits will not be paid until after the
Insured Penon's Deductible has been satisfied,
PART F - TarAL DlSABn.ITY 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
Fmod as specified in the Schedule of Policy Information,
1btal Disability benefits will not be payable for a Total Disability which results from:
I. sclf.lnfiiclCd injury while sane or insane;
2. war, dec1arcd or undeclared; or
3. normal pregnancy or childbirth (Complications of Pregnancy are nOI Cllc:luded),
No person other than the Primary Insured will be covered under Ihis Pan F. Your spouse or other dependents are not covered
under this pan,
Form MMFP-8/88 PA
PART G~ACCJDENTAL 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 lO.()()()
Both Hands..,....................,....................,..................................................,.........................................., 10.000
Both Fcet....................,..,...............,.........,.,...............................,...,.............,.........,........................,...... 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 FooL,....,..,..................................................................................,.........................,..,................., 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,
Ifmorc than one of the above 1055C5 is suffered due to anyone Injury. only the larger amount will be payable. If the
benefit is payable because ofloss oflife. it will be paid to your beneficiary, Other benefits payable under this pan will be
paid to you,
Loss of hands or fcetshall mean complete and permanent severance at or above the wrist or ankle joints: 1055 of eves or
eye shall mean complete and permanent blindness, .
Exclusloll5 From Coverage
This benefit docs 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 binh to the extent of the
provisions in this policy including the necessary care and treatment of medically diagnosed congenital defects. binh
abnormalities. prematurity. and routine nursery care, Such coverage shall be provided for the JI-day period after
binh. within which time the Primary Insured may submit application to continue dependent coverage, If a person
otherwise becomes eligible for coverage as a dependent after this policy has been issued, such person shall become an
Insured Person when:
I. we approve your wrillen application for coverage for that person: and
2, we receive payment of any required premium,
('
ft ~
,
ELIGIBILITY .
The members of the'Primary Insured's family who are eligible for coverage include (I) spouse: (2) unmarried children
including adopted children (including children pending adoption or in the procell of being adopted, provided the child Is
legally in the Primary Insured's custody), irthey a~ dependent upon the Primary Insured for support and maintenance,
and: (a) are lcuthan 19 years old: or (b) are full.lIme studenlllcssthan 23 years old,
TERMINATION OF COVERAGE
Your insurance and that of all Insured Penons shall terminate upon the oc:c:urrence of the fust of the following events:
I. the required premium is not paid within the grace period: or
2, the policy aMivCl'lllry following your attainment of an age qUlllifying you to receive Medic3l'e,
The insurance of an individuallnsuml !"trson 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 !"trson 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 !"trson's allainment of an age qualifying that Insured Person to
receive Medicare.
tr a premium is ac:ccpted for an ineligible penon after a termination date, coverage with rcspectto such penon will be provided for
the period for which premium has been acc:cpted, unless the renewal premium is not subject to change by reason oherminalion of
covcrage for such ineligible penon. exc:cpt where such acc:cplance was predicated on a misstatement of age.
If termination of covcrage oa:un by IClIson of non-renewal ohhis policy, while an Insured Person is totally disabled. coverage shall
cominue for a period of90 days beginning with the day following the date ortermination or non.renewal, pertaining solely to the
Injury or Sickness which caused the Total Disability,
CONVERSION PROVISION
A. If an Insured !"trson'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 allained an age qualifying you to be eligible for Medicare and this policy terminates. provided the
Insured !"trson 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 rcstrictions or periods of contestability lhat apply to the Insured !"trson 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 th is policy ends,
If the Insured Person has not been notified of his or her right to convert at least IS davs before the end of the
31-day period; ,
I, the right to convert will be e.~tended an additional 30 days, but;
2. in no event shall lhe additional period e.~tend beyond 30 days after the expiration of the 31-day conversion period,
B. If the Primary Insured dies while this poli~l' is in force. lhe surviving spouse shall automatically become the
Primary Insured, All references to the Primary Insured in this policy shall then apply to the surviving spouse.
tr there is no surviving spouse, all other Insured !"trsons shall have 90 days to purchase similar coverage without
giving us proof of insurability,
POLICY PROVISIONS
ENTIRE CONTRACT; CHANGES: This policy, including the enaorsemenll and the auached papers if any, con.
stitutes Ihe entire contract of insurance. No ChM....~ in this poli~l' ."MiI be vaiid 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 ill provisions,
,
TIME LIMIT ON CEIUAIN DEFENSES: After 2 years from the date of issue of this policy no misstatements,
c.'cept 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 c.'piratlon 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 los~ had existed prior to the Effective Date of coverage
of this policy,
NOTICE OF CLAIM: Wriuen notice of claim must be given to us within 20 days after the occurrence or commencement of any
Loss covered by this policy, or as soon thereafter as is reasonably possible, Notice given by or on behalf of an Insured or the
beneficiary to the insurer at ilS Home Office, The Harvest Life Insurance Company, Altention: Claims Dept.. 6277 Sea Harbor
Drive. Orlando, Florida 32887, or 10 any of our authorized agenlS, with informalion 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 claimant 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 requiremenll of this policy as to proof of loss upon
submitting, within the time rL,ed In this policy for filing proofs of loss, wrluen proof covering the occurrence, the
character and the e.'tent of the Loss for which claim is made.
PROOFS OF LOSS: Wriuen 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 contingent upon continuing Loss within 90 days after the termina-
lion of the period for which we are liable and in case of claim for an>' 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, e.'cept in the absence of legal capacity, later than one year from the time proof is otherwise
required,
TIME OF PAYMENT OF CLAI~IS: Indemnities payable under this policy for any Loss other than Loss for which
this policy provides any periodic payment will be paid immediately upon receipl of due wriuen proof of such Loss,
Subject to due wriuen 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 lermination of liability, will be paid im.
mediately upon receipt of due wriuen 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 indemnilY shall be payable to the estale of the Insured
Person, Any other accrued indemnities unpaid al the Insured Person's death may, at our option, be paid either
to such beneficiary or to such estatc. All olher indemnities will be payable 10 the Primary Insured,
PHYSICAL EXAMINATIONS & AUTOPSY: At our expense, we shall have Ihe right and opportunity to examine
any Insured Person when and as often as il may reasonably require during the pendency of a claim hereunder and
to make an autopsy in case of dealh where it is nOI forbidden by law,
LEGAL ACTIONS: No civil action shall be broughl 10 recover on Ihis policy prior to the expiration of 60 days
after written proof of loss has been furnished in accordance with the requirements of this policy, No action shall
be brought after the expiration of 3 years after the time wriuen proof of loss is required to be furnished,
,
.
, .
.,
~
ORACE PERIOD: Unless not leIS 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 aranted for the payment of each premium falling due arter the first premium, during which grace period this
policy shall continue In force.
REINSTATEMENT. 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, lIpon
the 4Sth 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 UlSS resulting from such
accidental injury as may be sustained arter the date of reinstatement and UlSS 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,
BENEFICIARY: You have the right to name the beneficiary for the Accidental Death and Dismemberment Benefit, You
also have the right to change beneficiaries by notifying us in writing, The change will be effective 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 the Effective Date as specified in the Schedule of Policy
Information,
CONFORMITY WITH ST ATE ST A TUTES: Any provision of this policy which, on its effecti\edate, is in conllict with
the statutes of the state in which the Insured resides on such date is hereby amended to conform with the minimum
requirements of such statutes.
ASSIGNM ENT: When permitted by state law, you may assign the benefits ofthis policy. The assignment will not be binding on
us until a written copy ofit is received at our Home Office, We are not responsible for the validity of any assignment. The rights of
the beneficiary. if applicable, will be subject to the rights of any assignee.
MISST A TEMENTOF AGE: Iftheageofthe insured has been missulled,allamounlS payable shall be such as the premium paid
would have purchased at the correct age,
INTOXICANTS ~ND NA~CO~ICS: The insurers~all not be liable for any loss suswined or contracted inconsequence of any
Insured Person bemglegally mtoxlcated or under the mnuence of any narcotic unless administered on the advice of a Physician,
All periods of insurance begin and end at 12:01 A,i'vJ" Standard Time. at your place of residence,
IN WITNESS WHEREOF, The Harvest Life Insurance Company has caused these presents to be signed by ilS
Chairman and Executive Vice President,
~/P
J.
')sliP ' 63.-
Iw
Chairman
Executive Viel Prnid.nr.
ADMINISTRATIVE OFFICE
8277 SEA HARBOR DRIVE
ORLANDO, FLORIDA 32887
)}K{(
HOME OFFICE
COLUMBUS, OHIO
The Harvest Life Insurance Company
(An Ohio Slock Corporation)
MAJOR MEDICAL POLICY (FAMILY)
HOW TO FILE A CLAIM
In C:lSe or Loss ror which claim is to be made. notiry in writing:
The Harvest Lire Insurance Company
Alln: Claims Depl.
6277 Sea Harbor Drive
Orlando. Rorida 32887
Be sure to Slate:
(a) Your complete policy number:
(b) Your present address:
(c) Date or Injury or Sickness and nature of Loss:
(d) Name and address of attending Physician:
(e) Name and address or Hospital. ir you were confined,
Written notice or claim must be given within the time period stated in this paUc:y after the Occurrence or commencement
or any. Loss covered by this policy.
\.
l
YORK OB/GYN ASSOCIATES, LTD,
1399 South Oueen.Slreet 3130 Granllview Rd.
York, PA 17403 Hanover, Pa 17331
ACCOUNT NO
1
PAGE NO:
15840
James W. Smllh. M.D.
Jay R. Jac:kIon. M.D.
O.d., H. Qortach, M.D.
Mary O. K'~l1ing. 0.0.
D.boran J. ""non. M.S,N.. C.R.N.P
Chna.... L. G.... '.tS.N, CR.N.P
TAX 1.0. . 23-:111,"
BilliNG DATE: 02/27/95
DATE OF LAST PYMT:
12/02/94
PLEASE PAY ON OR BEFORE: 03/15/95
1854.00
AMOUNT DUE:
AMOUNT ENCLOSED:
Christine M Layman
555 East Butter Rd.
York PA 17402
:",,"'QllUCI,,;~f eut fO"''' 0 .......,,"CAAO 0 'MA
II I Ilo::o:J III1II11
PRINT
NAI"E.
/
EXP. DATE
SIGNATlJRE
DETACH -'HO RETURN THIS POATlCN WITH PAY'-IENT
STATEMENT FOR PROFESSIONAL SERVICES
CHARGES AND PAYMENTS RECEIVED AFTER THE ASOVE BILLING CATE WlllAPPE.R ON YOUR NEXT STATEMENT.
DATE I PROCEDURE I CttARGES I AWUSTMENTS I PAVMENrs I UALANCE I
08/18/941 58150
I Abdominal
I
Hysterectomy
1854,00
.00
Patient
Medicare
Insurance
.00
.00
,00
1854,00
i
i
!
.. statement Due upon Rece~pt . TnanK You ..
AMOUNT
1854,OC
. WE HAVE BillED YOUR INSURANCE
ANY OUESTIONs: PLEASE CAll AND ASK FOR THE BILLING OFFICE AT (717) 854.0492
9 Safeguard' ll:....~ ,,",)
SERVICU A!HDERED
Summary of Charges
250/PHARMACY
300/LABORATORY
120/ROO~-BOARO/SEMI
260/IV THERAPY
270/~EO-SUR SUPPLIES
410/~ESPIRATORY SVC
360/0R SERVICES
370/ANESTHESIA/SUPPLIES
320/0X X-RA Y
402lULTRASOUNO
710/RECOYERY ROO~
310/PATHOLOGY LAB
259/0RGS/OTHER
CHAAOU OA CREDIT
LAY~AN,CHRISTINE MARIETTA
'ATIENTNU".O. ~ 1 B 768'564
PLEAse REFER TO THIS PATIENT NUMBER
ON ALL INOUIRIES ANO CORRESPONDENCE
IF YQU HAVE QUESTIONS REGARDING THIS Bill. PLEASE CAll '717 J 8'H - 2544
SERVICE 8Y RADIOLOGISTS
ANESTHESIOLOGISTS AND
CARDIOLOGISTS ARE NOT
INCLUDED IN THIS BILL.
725.35
262.9'5
1,896.00
289.'50
130.7'5
57.7'5
2,099.40
3Q7.60
52.50
284.00
164.00
257.00
25.2'5
..............
00-14-1994
03-14-1995
03-14-1995
TOTAL
PAYMENTS PRIO~ TO INVOICE QATE
COMMERCIAL INSURANCE
REJECTEO-CONTACT YOUR CAR~IER
6,642.1'5
0.00
0.00
0.00
~E HAVE BILLEO YOUR INSURANCE. PLEASE PAY THE
A~OUNT SHOWN ~ELOW AS "OUE FROM PATIENT".
THANK YOU.
p,utENT N....!!
DUE FROM INSURANCE: 0.0
OUE.~ROMYOU ~ 6,642.1
PAYMENT DUE BY, 03-29-199
,~_ J
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 my knowledge, information
and belief.
Date: dl/lM/9y
~.
hnstme
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 mail, postage
prepaid, upon the fol1owing:
John M. Noble, Esquire
MEYER, DARRAGH, BUCKLER, BEBENEK & ECK
114 South Main Street
Greensburg, PA 15601-3102
KORSAK & DeARMENT
Date:tjS/qu
.,
By:
I
.,
Josep
33 N Queen Street
Yor PA 17403
(717) 854.3175
),0. No. 22233
Respectfully Submitted,
WHEREFORE, Plaintiff prays entry of judgment against the Defendants in
the sum of $9,831.15 plus costs of suit.
Date:
January 4, 1996
KORSAK & DeARME]T---
.,,)/'//
Joseph C. Korsak, Esquire
33 North Queen Street
York, PA 17403
/ (717) 854-3175
,...../ 1.0. No. 22233
~
i en ~",'
('oJ
& g""'
16 x: ~
8 0.. 8~
~"."~
('::. ~~;
c-
ut ::r. '_:ilD
F "" ,.o~
-, ....;
b ..n :5
0' u
I
f
I
i,
I
i,!
f:
,
I
~
'..,"'1,,""'7' :~
. .
.
..
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
CHRISTINE M. LAYMAN
Ny. 95.7194
\/No. 95.7195
V8.
THE HARVEST LIFE
INSURANCE COMPANY
CIVIL ACfION . 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 ACTION
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.
DISTRICf COURT ADMINISTRATOR
CUMBERLAND COUNTY COURT HOUSE
CARLISLE, PENNSYLVANIA 17013
(717) 240-6200
Date:
By:
February 16, 1996
Korsak, Esquire
33 No Queen Street
York, PA 17403
(717) 854-3175
1.0. No. 22233
....,..;........-
'. ...,.. ':'... ....
..~""',,.,...~..;--""".,.~.,,_.~.,.;..,.y,.,~;.....;...:..~>"""'-,.,~~~.~...~~
,,"','
. ,.
.
....
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 mail, 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: ~P/t(J/qr
By:
. Korsak, Esquire
33 No Queen Street
Yor PA 17403
(717) 854.3175
I,D, No. 22233
(412) 836-4840
"
IN THB COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
CHRISTINE LAYMAN,
Plaintiff
va.
No. 7194 of 1995
No. 7195 of 1995
ANSWER AND NEW HATTER
TO PLAINTIFF'S COMPLAINT
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
GREENSBURG, PA 15601
JOHN H. NOBLE, ESQUIRE
Pa. I.D. #36933
TO ALL PARTIES:
You are hereby notified to plead
to the enclosed Answer and New Hatter within
twenty (20) days of service hereof, or a
default judgment may be'entered against you.
..-:>--")/ i1--- ~
JOHN K;' NOBLE, ESQUIRE
ATTQRN];lY FOR DEFENDANT,
HARVEST LIFE INSURANCE COMPANY
//
.'
,
.'
"
IN THB COURT OP COHMON PLEAS OP CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
CHRISTINE M. LAYMAN,
plaintiff
No. 7194 of 1995
No. 7195 of 1995
vs.
THE HARVEST LIFE
INSURANCE COMPANY.
Defendant
ANSWER AND NEW HATTER TO PLAINTIPP'S
CIVIL ACTION COMPLAINT
AND NOW comes the defendant, The Harvest Life Insurance
Company, by and through 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 Paragraph 1 of said civil Action complaint,
after reasonable investigation, the within defendant is without
sufficient information or knowledge 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
pertaining then and thereto.
2. In reply to Paragraph 2 of said civil Action complaint,
the allegations contained therein are denied. Rather, The Harvest
Life Insurance company is addressed at 6277 Sea Harbor Drive,
Orlando, Florida 32887.
3. In reply to Paragraph 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 Chriotine M. 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 M. 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 ultimately resulting in plaintiff's
hysterectomy and that plaintiff's failure to truthfully and/or
otherwise 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.
B. In reply to paragraph B 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
male or female disorders".
Plaintiff Christine M. Layman
.::",
:.1
in its favor with costs sustained.
By way of further Answer, defendant The Harvest Life Insurance
,
. /..
..~~
Company asserts the following New Matter:
NEW MATTER
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 "geni to-ur inary system (kidney, bladder,
reproductive organs, etc.) such as infection, bleeding, stones,
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. ~
))aae 2 of a))))lication 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
.'
following recision of plaintiff's policy of insurance with a return
of all premiums paid on the policy in the amount of $5,173.86.
12. Based upon the provisions of the subject policy of
insurance, plaintiff's fraudulent misstatements, misrepresentations
and/or otherwise failure to provide truthful and/or accurate
information 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 judgment in its favor with costs sustained.
6
~
Respectfully submitted,
MEYER, DARRAGH, BUCKLER,
BEBENEK & ECK
By:
JOHN M. NOBLE, ESQUIRE
Attorney for Defendant
The Harvest Life
Insurance company
7
<:A94'0406, AOl
"
.~.',~ ..~.1 ~ ~,4:-;~lf;~.. ,'. :~.rJt: f:",' .;.;~\~ r~;'.:: ~~l~)t;- "":III,'"i'..f"""~'-f
"'4
.'
..:.;::;\
- ,
.:' ~ 't'::
;;'-....~:~j.:
;;.',\h..;
'. . .. ' ~:.
i~~
- '~':;:"\'
',IP;.f'~'
..! ...:;~
":;~;Xr:::'
,.~'/~~~
....-:..;.:
'i::~?~~~
./~;f{j~
:C"..:.","
'...,'.....
?~I
..~,\'..r,:Ir-n;
~t~
,;~..:.."/:,.~.
", - . ~
;~i)gE
.'... ('/.
PA"T' - PAnT 2'
.. ." ,...-..1. ..-...d"''''' P. hA...... _ ",",":"-.b;"-';~' IWf'Ift. .....- ~ f:31
tin aooy p"loOn propuwd 101 ill",,'''''':
Z:' 0.." ",Nlall, oj~9nosed Ot "utili 10f jn'f d~..,..
oral.OId,tol-
I "1'ollaloryl'f'hI'" Ilunqt.b'OIlol;I'lI.I'U,.....IC.lllld'l.ll1 18.
a..run.a.~O"ySl"'..tlIOf'lC'nlll' ................
b ClrcloIlllory "tl.,,, (h..rl blcQd, .nfl"" ...,n.. IIC.)luCi"l Ii
1Io9Ilbl~"I.a""..".lrt.lI.cll.".u'''''''1 .........
c:. O'~nl'v. ",,1<1'" letapl'''QU1. tlOltlaC". .nlutu',. N....,. I'll
bloldd.r. ,Ie,I Il1e" " Ill,." ClIIIlO.... ".mOllnO'''I.
tllCtd,n1' ..............................
If. NeN'OVI ')'1"'" Ib'ein. "Itf"fa. cIC,) wel'l U p."ty1o../aoIl"
j"9, .,ulepIY. co".uI110"'. meltlal 0' ".'.Iun ~I"
0'4"'" ............................. ...
.. "'.neule' 'ltd .ulclal,.,.1""'1 ImUK1"- bCll'lMr.loonl s;l11I_,
'lC.J.ucII"ne-cllQ'lIlClIproN""'ll,'''CI"",,'''''''li',';CI\II
a"m~lahO"' ...........................
f, C""lto-lIti...'Y ..,.,Ie,., "ICftrt. N.dd..., ~ptl)d""""'" 0'1'"1.
"c.) ,."cI'I u inlochon. b1ft'ditwj. ,len.1. 11'I'" Of Itm.al. oi,.
Old."?...............................
g. Q,ndlll4l, IY'lem lll'l,u~d. PoI""e.... ,dltNl.'I""Dh ~"nd',
IIC.) 'u,,, al d'.b.I.... a' .llna,m,1 11'0"1'" elt
IUII<I,on? ........................... ...
n. l!.., bMIn d'IQ"ow:<J Cy' pnY'looC~" as".....!) A'!1"'t1'lS 1m",,,,....
O'.,o....,y .t,rId,arne rAIDS1. A.dl R..lld Co",plul-AjIC-J
Otb-""II,U'o,AIQS' ......................
24 t.., IISIN po',II'" 1M at'lllbodin 10 \11. AleS iH\lm." T.~ll
L,mIll'OIlOOIC. T.," lit; H1lV.Hll-,,'ul' .............
n [.., Mt'ft m.-dOc..l'Y '11I11" 10' 4l$Otdlf 011lY'l1 Of~, UflGtt.
c.,llo' lumOf, 'ICtlC",ld,..-.rw-"..otn..,obaaW' ....
:lll!..' ~.~ r;'I)""'''' ll.,n. """,tI<li'f 01 poK'l pef d'y' -
IIQ,,'I,wn."' _w.'_ '''''-'-- --
t1 E..r "'d 4I'we(lliufUoI$U'pc'rtdc:d at ITOoIlld"U Yt'l.liu"..."
1~ ,"0
c/
c.d'
cJ!
'n No
::s. E.er mid.." Iltl\.lf'I'~ d.,m '0""1"''''''' \lc~".", ..... 0....::'
..u .n., potllO" 1l10~ In, II"""'I'CA. " ~, ")'Q\I ~1IC7W IIld
botli...:
:'J.w,trll","."adS.,-..n:
L )-Uti .", 01"., .CU'~ or IIIIJ'" ""lJ'CoIl'1 dl,lQ~ Of
1,....IN:at....d.n'o..7'OIIIC;I.C~h....UUI&S;C."Y.!,(a. 0 .-
l"lIontory~I' .......................... ..cI
b. l-4,d ",,~,ry 0' G".."I,O)". ~n u"cl.... otrwN.heln 0' 1,.,1..
_/It.P'.ICI'bIoddlCl<:r~<.tIoC"0'tI.u.,l/W'~n.l4,,_1
~con"""cl' ............................ O~
c. R.c.,.~ cllutoijtp ~II."I,. wel'''''''''.. CofftIl......hCl" ot
bMIrl~a:iCJl"O:d\olf7rl'I'C"'N'"iItV't'C'phpialOI~
,.&JIIl".?..............................
ap.
0;/
d. RteIo~..c..,.ol~d",.;I,."NtrI'I",."f1 .........
.. HWCfl.'lp.I'''.&hOll''lUcltll'.''".toug"~"C1...-uOt
""&dId'.I'..................... ........
:.0. BoN"....':Oc..'I., 4""i1natold cruulld lOt l"YoI".' l"lllry. di.....
o'daalcl.t"o'.~t........................
11, My"'. i"wlln"o"t'O"lIllfWNlIl ~\nl'd. po\lpIJ"-.t, rinlottd.
011.,., or ~0CI11d 011' 'Iltl:lUl'cl.I'd 01 r.alll<l t'.uIl' ......
31. MY pill pre&'f'1 0' up-<:e<<;
a. A"""Of\'CIMIICS,ll;:,rCtOfCtI...m""tl."..........
1).H.a.ta'~IlI..c1NoI....'CI'Or.r."""c.lI-.I'ICl"Cln'......
nllr..""",.
a. A"yp.oIIO<IIl'rlof'fIIC;IOlOhc.D0f'I,C11l11"1I\anC',t ......
II. 'loJ<of""..,l\&nt1............................
09"
o.,!
0,L
0;/
~1
0/
)4.'."""'cl~ ..' U l.,~1O (T"'t'(I~
Ad4tIU eJ....'" ,.. J<. t.d- o,J...,t_
o.ll'aUCQlUWIIId -.~,.. 1'1,1
R-no" oVId rMUlLS t. ..1 J T - )-~{...
po
-
tJ ~I"''''
0_
....
-.....
.. ........
D," N..,.. ,,., Iddrtllt ",...:11 IMCIDt.
w...JYt. ",...UI 01 CDf'I"OI"y.
~ 0.."", 'or' ItN't -.... '''~ g4 1I1J~11Q1t. :211\f~1I ~ Ib~CI C,WIU fa, ."1'" .,elJ II,".. r;glM/lled I :lI'I'fSICUI" 01
pnc:'IoO""" "ttwr lull,....,.." la''''''' "".an 1/'14 .)bQ",\:
~.. I.,.. ____ hd.Idnt -"" of "--.
-"'r.~..,--.t MdI_ltll.
, =t
--~-
I
I
"I
I
---:-=r'
'j-
=+=
~}-
a.cf
OD
0.....
aJJ'
00'
o.d'
0:>'
0......
.. I _.>_....-? ~,!..
...... .) ~J ~bee" "",d IDI"e ~t"1. subl.cllan:'l"'"JI"s.Ilit"c( '"lJfI'!aj 0., '", Co3",g,ny.
1[04' W'I 1l,...,Udandu"dmtand all aoo.... ,Ul,",CO'IIIM .N....". To Itlel M,I I'll my IC'~fl'"C1W r::;..1'd tMMlf, !l'\...,a'l!' ,,,,.. .rodco",a"'e.rtd
COUf"Ctll' 'KOfded. and 110' We) "a~ .lId III' Nolle. 10 ,l~p4ic.JIII .",(It ,"dlld~" I..... 1""",*,;.".. c",..."".." Reoott No~ .I'd III. l,ledClI
Inla,,",,,,loQ" eU'IUlI c.IC.loIoul'e NOllt.O.
Any PfOOOII'd ''''Su,C'lf ..n(l '''0 Ow"....r ~Ih"t III." I'" mOClwd 1",,,,"d. "lln:'$L'l"lll 'NlI,I1t ,lI1rm."U .,,(1 art:W"n eel'l',,,,.d 1ft Pvt C_ IC'I'f"-
...Ih 1."1 ow made'lI "';1,,1_0.'. 10 !lie bt'U 01 tlllO'"" 10' 11'Io!"lk"o.le-dq..nd br"~. '\Ill. c::me.." 'I'd 1""",1' ...""""0111"'.1'. cor":':IYltCord".IM
ua....~y ''fIW.u 10l10.....c 1'.1 Trill allPlot.lhQn. ."d 11I.,,,OOC't 0' :>QtlCliI'$,nue<l I"all co,,"""" tho: ~I,,. eon'"'' al ;"'\11,""": 1M ,,... COftIOI""
I~U not II. DDIJI'dil\ ,",~1 "'" .n.,ILatl:"'",Il. :l'D"""" a,,,,IOtmlhO" ,,"a. Qf 1'.0:"11., ot 'a."., ......101 QIl"lCr ....",01'1 I' ."yt.,,", ~Ioru 'lIew""
tit ." .."11"9 .nd .,,""'IIIN la ,t'lo c,,"'/lIn., II ,'s Haorle ClI.c. Jro:I ",.adl .. CUlf 01 llIUI c.c"lr.act. eM.,. I l:4'"Il'I'Y ella' ~.., mill. tnOd"y 01
alK:-"O;o con,,"CII atw.,..., Jny olll"lct ~,"p.I"y'1 "';"11 0' .tq....'M1.."U..1'd "".. on'Y i" _'11"1. r:.1 fl'l' ,..s...UIIC' r,el.by JllQ400t'd '0' :.hdnol ~
c:nlldltfC'd in 'OtC.unlll, j)Ol;c.., .".. "',..0 !lei" ,Ul.ICd "., 111. CiJ"'~"Y 'rod ~,lJ 1lQ1',", m..."...".1y Ptt.,,,.,q ,nd .KCft)"O bv ,". 0.."" .It'dl''. "nJ
p...m'...... Il~>d.,l/I dU""9 I". good "~Ih 01.", ,,"'pO'....tl\lloll-.1. ,1'hO '...llin.' fI'.'""''" 'llIltIJ ,1'\ .4..'I'ca la.an IUU"Ie",C'd 1qtt'lllJt'". C3,"O:ll"'I'
..-h," .a"., P1apo," I"W'" "1" good,,,.llth aM'''''' CDrltlllO'\.lll '_1'110" Ill! 'a"""'~'''.s 'IQtIt....'t<J IQ IIWaw"",II'W","e "10011'., IJ-ItM C:I'"\UIl"
'NIl tle" "'''lid 1I'\''''''tt:<eorol 111 Pouc:yo_"""o..olI0..'....Ia_Uc.a/lyIO P"W~ I"su''''~ O"'Of'cl'IIIIln 010."<<. u",.u ''''endcod olJler-_
!)'I'C....."f:f.
.""
'..UIIlO"''' ..ny ghy,ic::ian.l'lOSD,U.I,'liniC.MOIIWt mldoe..all., "UII'!:J',cJIt't.inwUttCe C:3111p.tWly. tnelM'JlcalltllO""lhon f111'UU,IltQ'l'lwOM)lfIlr,allan
at PCrsar'l 10"''''' IIIO""r'II'C"Sot ",'.IOl'IJ"f'lQ C4"'llo.It'I." otll1''''''U1C" ,n,.,.,s IIllnlOmulllef'l ....'h,.I4'tnC.lamtOt"'yl'WUlll'l,. w~ ","""",blnal
my ,..m.ly IOt"""iCI\ C~1f I' PlCl)Oll'd. A Pl'lOloql'1phc copy aJ ll't1t IIMOlillhan IhIIl be U ..Iia U 1'- :)tI9,ruL 13110 lCal'Q'oO"C;lll'lClt>P1 crll..
NOTICE TO APM,ICAHT PIns A Ind B.
$ion<<! 10'-1<'
II. .. _. .
"'"
PA
.1._. ...
Slalll
7:.L"_ ..5~
"OIe,y Y.v
I ~Iyl"'" '"'..INl't .nd..u;unl..."ecol"dll'don 1lI.IClClliC:Illon Il\II
Ifllarm.\IOft ",pplled by 1110 p,Q9OMd IltlUlld~-,-CW' 0.-<<. TIIIl\II
t)ft.l at '"T ~nowttdq" ''''a rol.M lOt n dOCn 1"'""'Vcet not cnlnq' 01
'1'1)11C1t ""y,.i,eJUl4hl.."t'II'I\ 01 aNlu,lY plan.
'~ r~~l,l_
.~.'-- 109--'1
.
"
~7r.!..._
...,....1 No.
Ow".' :.1 "'...... Nn P1oaontd "'uar..al
111 bu:Io/l-.s ",.,,..,.0 IN'" ioU. al alllc.t.lllld n_QI tlfII'I'
.
EXHIBIT
I
"A"
Page 2
"
VERIFIED STATEMENT
I, John M. Noble, Esquire, 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 ANSWER
AND NEW MATTER 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.S.Section 4904, relating to unsworn
falsification to authorities.
,
~
"",
. I
I
,
.'~-
M. NOBLE, ESQUIRE
I
JOHN
DATE:
}..:2/-7C:.
-
,..
,
,"
.,'
,/
i.--/
"
"
"
CERTIFICATE OF SERVICE
This is to certify that a true and correct copy of the within
ANSWBR AND NEW HATTER has been mailed to all counsel of record by
forwarding a copy of same,
postage prepaid,
First Class U.S. Mail,
J/k
this J . ). I
./
/:
L
1996.
day of
Joseph c.Korsak, Esquire
KORSAX , DeARMENT
33 North Queen Street
York PA 17403
Attorney for Plaintiff
.'~.
. .
~...""
~ "
- ..:r "-
b; ,Yl ~~
5 ;;, -.'..:t;
~-' (.)~..
ft' , .- Us
"' ......
~.t ,', ..-j
, : r.:_
,..., : . 'f)
N .......
.>~..
ILL' : [{; \ i'liD
r-= UJ p~O-
...... .'.
'0. \0 :;}
0 C' CJ
, ,
.'
"."...-"-",".,..:,,,rc..'.'
4
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
CHRISTINE LAYMAN,
Plaintiff
No. 7194 of 1995
No. 7195 of 1995
vs.
SUPPLEMENTAL VERIFICATION
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
GREENSBURG, PA 15601
JOHN M. NOBLE, ESQUIRE
Pa. 1.0. #36933
(412) 836-4840
.'
.. ~'~~~-".~,,,,
"
~
FH-84554
VERIFIED STATEMENT
I, e- /().IIJ~ "G 6; h /Yl1.f1, being the,r~LU If" Co (j JlJr..R.. of THE
HARVEST LIFE INSURANCE COMPANY, am duly authorized to make this
Verified Statement on its behalf, and I hereby verity that the
statements set forth in the foregoing ANSWER AND NEW MATTBR are
true and correct to the best of my knowledge, information IInd
belief.
I understand that false statements made herein lire subjeot to
the penalties of 18 Pa. S 4904, relating to unsworn falsification
to authorities.
!lawv-j/~~~
"
Date:
U.;J../ /9 ,
"
~
CERTIFICATE OF SERVICE
This is to certify that a true and correct copy of the within
SUPPLEMENTAL VERIFICATION has been mailed to all counsel of record
by forwarding
prepaid, this
a copy of
~'K~
same,
First Class U.S. Mail, postage
::::?~1996.
day of
Joseph c.Korsak, Esquire
KORSAX Ii DeARMENT '
33 North Queen street
York PA 17403
Attorney for Plaintiff
JOHN M~~N B E, E QUIRE
ATTORNE FOR DEFENDANT
THE VEST LIFE INSURANCE
COMPANY
..... OJ:) ~
b;
~.~ .-
r~ ~
~n :',),.r;
.- ~- 8~
~) -~
~c u.. C);:~~
t' ..,,)
p '-.-, ~i...
UJL'. I "Z
~~l' rC ,D,i)
F :::.: ,""-
.. ,;~
l\. ~'....
u:> =>
U Cl U
.
,
.
,
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
CHRISTINE M. LAYMAN . No. 95-7194
.
. vNo.95.7195
.
V5.
.
.
II THE HARVEST LIFE
INSURANCE COMPANY CIVIL AcrJON . LAW
REPLY TO NEW MATIER
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 improper 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 medical 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.
:1
'I
I.
1
I
.
.'
13. Admltted in part. It is admitted that Plaintiff underwent the procedure
indicated. However, Plaintiff made 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 Submlued,
Date:
Jl' !;t
KOR~ DeARMENT
I .
C~ ----
Joseph C. Korsak, Esquire
/3.3 North Queen Street
~ork, PA 17403
(717) 854-3175
1.0. No. 22233
By:
il
.
.
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 my knowledge, information
and belief.
Date:
?!r./~,(,
~
I
I
I
I
I'
II
II
,
"
II
:;
II
;1
Ii
'I
II
II
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 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
KORSAf & DeARMENT
I
I
I Date: 7 J J I ~ ~
I
;
II
By: \~.
Joseph C. Korsak, Esquire
/,33 North Queen Street .
- York, PA 17403
(717) 854-3175
I.D, No, 22233
,I
.!
I
.1
I
-,
ii
!
0
... m ,-
!-
ir In ::
'j::. co; J.-r
lU~:' ). -"
". ";..
2' - -'~.~
Id- --
u.. ~.~~
~r t.:) . ,r,
,t., I : ~l;~
_1,,, r~ , ;,:J
tr:- ...: l~l~
I ....
If- ,l) :..:.)
Q ,-. U
,_"_'f.'.~ '-\<.'".',;,<"~<~!",.,:."y-.~,,
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
CHRISTINE M. LAYMAN
.
.
No. 95.7194 /'
No. 95.7195 v
.
.
VS.
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 Life 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
m , PA 17403
(717) 854.3175
1.0, No, 22233
i
I
I
I
!,
,
~ Lf)
~ c-.
.. '.'
(, C'~
~t ..'
lo ,'.
LO: ':".
~... .:-j
,. Cl .Ul
1_' ('J .z
&:" !;' . -.I'
,m
,h -' ~o..
.' ..~
'0, ,-..:
0 ,e, )
Date:
November 21, 1996
By:
IN 11IE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
CHRISTINE M. LAYMAN
No. 95.7194
No. 95.7195";
VB.
1HE HARVEST LIFE
INSURANCE COMPANY
CML ACTION. LAW
PRAECIPE TO SETTLE AND SATISFY
TO TIlE PROTIlONOTARY:
Please mark the above-captioned actions settled and satisfied of record. .
K?R DeARMENT
J C. Korsak, Esquire
North Queen Street
York, PA 17403
(717) 854-3175
J.D. No. 222:13
>- 0\ r-
q; CO:
~ :?:
~9 M :~.) <r'"
(~)~
c: .- ..J.<
~r "'- ~-
~ 1~.J
N -..;0-
u. N
1I!u :=' ~ ,,--~
'~'l,O
r-= a !";Ju.
:.:: -'"
"- -.0 :::l
U en U