Preview
CASE NAME: CASE NUMBER:
McKeone, et al vs. Ramos, M.Du et al 23CV00044
!
4. Incident or accident The incident or accident occurred as follows:
a. Date and time: 11/8/21
b. Place:
c. Persons involved (names): sussnne L Ramos, M.D., sussnne L Ramose, M.D., Inc. Bnd dalmant's mother, Haylee McKeone.
~ Continued on Attachment 4.
5. Nature of incident or accident
The facts, events, snd circumstances of the incident or accident are (describe whet happened):
Negligent medical cars and treatment of dement's mother, Haylee McKeons, resulted in failure to timely diagnose snd treat her breast cancer.
Minor daimant hss a potential wrongful death daim.
~ Continued on Attachment 5.
6. Injuries
The following injuries were sustained by the daimant as a result of the incident or accident (describ):
Minor daimant has a potential wrongful death daim.
~ Continued on Attachment 6.
7. Treatment
The daimant received the following care and treatment for the injuries described in item 6 fdescn'be):
~ Continued on Attachment 7.
8. Extent of injuries and recovery (An original or e photocopy of any doctor's report containing a diagnosis of fhs claimant's injun'es
or s prognosis for the claimant's recovery, and a report of ihe cfaimant's cunenf condition, must be attached io this petition as
Attachment 8. A new report is not necessary if a previous report accurately describes the claimant's current condition.$
a. ~ The daimant has recovered completely from the effects of the injuries described in item 6, and there are no permanent
b. ~ injuries.
Ths daimant hss not recovered completely from the effects of the injuries described in item 6, and the following injuries
from which the daimant has not recovered are temporary (describe the remaining injunes and symptoms):
c.
~ Continued on Attachment 8b.
~a The daimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries
from which the daimant has not recovered are permanent (describe fhe permanent injuries snd symptoms):
Minor daimant has a potential wrongful death claim.
~ Continued on Attachment 8c.
MC000 tnau. January 1, 20211 00002af10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION DR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISASIUTY
CASE NAME: CASE NUMBER
McKecne, et sl 00. Rsmcs, M.D., et El 23CV00044
! !
9. ~e Petitioner has made a careful and diligent inquiry and investigation into the facts and circumstances of ths incident
or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent,
and seriousness of the claimant's Injuries. Pelltioner understands that It the compromise proposed in this petition is
approved by the court and consummated, the claimant wffl never be able to recover any more compensation from the
ssttgng defendants named below even if the claimant's injuries turn out to bs more serious than they now appear.
10. Amount and terms of settlement
To settle the daim in item 3a or 3b, the defendants named below have offered to pay the following amounts to the dsimant:
a. The total amount offered by all defendants named below is (specffy): $ 950,000.00
b. The defendants and amounts offered by each are as follows (specify):
Defendants (names) Amounts
Sussnne L. Rsmcs, M.D. End Sussnne L. Ramose, M.D., inc. $ 950,000.00
$
$
$
~ Defendants and amounts offered continued on Atischment 10b.
$
c. The terms of settlement are as follows (if the settlement is fo be paid in installments, both the lolsi amount snd the preseni value
of the sefflemsnt must be indudsd):
From the gross sealernent cf $950,000.00 for petitioner'0 medical mslprstice 0000, less sltcmeys feeS in the amount of $ 31 0,292.24, less
case costs in the amount of $9,720.50, less cost reserve in Ihe amount of $ 1,00.00 leaving 0 net of $598,98727 to Petitioner with dsimant IC
receive $ 30,000.00 for her potential wrcncful death Ecscn.
~ Continued on Attachment 10c.
11.
a. ~
Settlement payments to others
No defendant named in item 10b has offered to pay money to any person or persons other than the daimant to settle
claims arising oul of the same incident or accident that resulted in ths claimant's injury.
b. ~~ To setlle claims arising out of the same incident or accident that resulted in the claimant's injury, one or more defendants
named in item 10b have also offered to pay money to a person or persons other than daimant.
(1)
{2) Petitioner ~e does not have ~
The total amount oifersd by all defendants to others is (specify): Gross mad r0sl Eealemenl $
hss a claim against the recovery of ths dsimant (other than for
reimbursement of fees or expenses paid by petitioner and listed under item 14).
950,000.00
(if you answered Tres, explain in Affschmenl 1 fb(2) the circumslsnces and the effect your dsim hss on the pmposed
(3) Petitioner ~
compmmise of the dsim described in this petition.)
is not ~e Is a plaintiff in the same action with the claimant.
(If you answered "is," explain in Attachment 1 f0(3) the drcumsfances and the effect your daim and ifs disposition has on
the proposed compromise of the claim or scffon described in this pefffion.)
(4) ~e Petitioner would receive money under the proposed setllement.
{5) The settlement payments are to be apportioned and distributed as follows:
Other olaintiffs or claimants (names) Amounts
Peblicner Hsylse McKscns snd hsr husband Lucss McKecne $ 588,987.27
$
$
{6)
~ Additional plaintiffs or daimants and amounts are listed on Attachment 11b(5).
$
Reasons for the apporbonmsnt of the set5sment payments between the claimant and each other plaintiff or daimant named
above are specied in Attachment 11b(6).
MC000INee. Jeeeeer 1,2021I Page 0 er 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS DF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
CASE NAME: CASE NUMBER:
McKeone, et Bi vs. Rsmos, M.D., Bt Ei 23CV00044
!
12. Ths claimant's medical expenses — Including medical expenses paid by petitioner, Medicare, Medi&st, and private
insurers —to bs paid or reimbursed from proceeds of settlement or judgment
s. Totals
(1) Total medical expenses before any reductions: $
(2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): (3 )
(3) Total of negotiated, contractual, or statutory reductions, if any: ($ )
(4) Total medical expenses to be paid or reimbursed from the proceeds: $ 0.00
(5) Total amount of statutory or contractual liens, if any: $
b. Medical expenses were paid and sre to be reimbursed from the proceeds as follows:
(1) ~ Paid by petiTioner in the amount of:
(2) ~~ Paid by private health insurance or a self-funded plan under:
~
(s)
~
(b)
An Employee Refiremsnt Income Security Act {ERISA) insured plan.
An ERISA self-funded plan.
~
{c)
(d)
(e)
A Non-ERISA insured plan.
A Non-ERISA self-funded plan.
Amount paid by plan: $
~
(f)
~~
Amount of reimbursement to the plan from the proceeds of the settlement or judgment:
(i)
(ii)
No reimbursement is requested by the plan.
Reimbursement is to be made to the plan, and:
~
~
(A)
(S)
(C)
There is a contractual reduction of:
There is a negotiated reduction of:
No reducfion hss been agreed to,
($
($
).
),
for a total reimbursement to the plan, in full satisfaction of its lien rights, in ths amount of: $ 0.00
(3) ~ PaidbyMedicareintheamountof:
less the statutory reducfion in the amount of:
for a total reimbursement to Medicare in the amount of:
(ANsch a copy of the gnal Medicare demand letter or letter agreement as Attachment 120(3).)
(4) ~~
(a)
Paid by Medi-Cal in the amount of: $
Nofice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code,
~~
(b)
is attached ~
5 14124.73.) A copy of the notice and proof of delivery:
was filed in this case on (date):
Notice of this daim or action has not been given to the Director of Health Care Senrices. (Explain why notice has
~
(c)
not been given in Attachment 12b(4)(b).)
In full satisfacfion of its lian rights, Medi-Cal has agreed to accept mimbursement in the amount of:
$
(Attach s copy of the gnat Medi-Cal demand letter or letter agreement as Attachment 12b(4)(c).)
~
(d) Petitioner is entitled to s reduction of the Medi-Cal lien under Welfare and Institutions Code section 14124.76 and
~
~ (i)
(ii)
(check one):
Is filing a motion seeking a reduction of the lien concurrently with this petition.
Requests that the court reserve jurisdiction over this issue.
The amount of the lien in dispute is: $
~
~
(5) (a) (i)
(ii)
There are no statutory or contractual liens for payment of daimant's medical expenses.
There are one or more statutory or contractual liens of medical service providers for payment of claimant's
medical expenses. The total amount claimed under these liens is: $
In full satisfaction of their lien daims, the lienholders have agreed to accept the sum of: $
(Pmvlde requestedinformsllon for each lienholder end other specllied medical service pmvlders on next page.)
MC0% IRfe. Jaeeafr 1, 2021i Page 4 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
CASE NAME: CASE NUMEElt
McKeone, et ai vg. Ramcg, M.D., et ai 23CV00044
! !
12. Claimant's medical expenses (continued)
b. (5) {b) Thenameofeachmedicalserviceproviderthatfumishedcare andtrestmenttoclaimantand(1)hase lienforallor
any part of the charges or (2) was paid (or will bs paid from ths proceeds) by petitioner, for which payment petitioner
requests reimbursement; the amounts charged and paid„ the amount of negotiated reductions of charges, if any; and
the amount to bs paid from the proceeds of the settlement or judgment to each provider are as follows:
(i) (A) Provider(name)
(8) Address:
(C) Amount charged: $
(D) Amount paid (whether or not by insurance): ($
(E) Negotiated reducbon, if any: ($
(F) Amount to be paid from proceeds of settlement or judgment: $
(li) (A) Provider (name):
(8) Address:
(C) Amount charged: $
(D) Amount paid (whether or not by insurance): ($
(E) Negotiated reducbon, if any: ($
(F) Amount to be paid from proceeds of settlement or judgment: $
(iii) (A)Provider (name):
(8) Address:
(C) Amountcharged: $
(D) Amount paid (whether or not by insurance): {$
(E) Negotiated reduction, if any: ($
(F) Amount to be paid from proceeds of settlement or judgment:
~ $
Continued on Attachment 12b(5). (Provide information about additional pfoviderg in the above format, including
provlderg paid or to be paid by pelltioner, for which payment reimbursement is requested in item 12b(1), above.
You mey use form MC-350(A-12b(5)j for this purpose.)
13. Claimant's attorney's fees and ag other expenses (except for medical expenses), including expenses advanced by
daimant's attorney or paid or incurred by petitioner, to be reimbursed from proceeds of settlement or judgment
a. Total amount of attorney's fees for which court approval is requested: $
(ff fees are requested, attach ss Altschment 13e s declaration from the attorney explaining the basis for the request, including a
discussion of applicable factors listed in rule 7.955(b) of the Cel. Rules of Coun. Respond to item 17e(2) on page 7 and attach a
copy of any written attorney fee agreement ss Attachment 17a J
b. The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted
from ths incident or accident, and should be paid out of claimant's share of the proceeds of the settlement or judgment:
Items Pavees lnamesi Amounts
$
$
$
$
$
$
$
~ Continued on Attachment 13b.
$
Totah $ 0.00
MC400 [Rae. Jaeovy 1, 2021i Page 0 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
CASE CASE NUMBER
NAME.'CKsone,
et al vs. Rsmos, tet.t3., et Bl 23CV00044
! !
14.
a.
b.
~
Reimbursement of fees and expenses paid by petitioner
~
Petitioner has paid none of the fees or expenses listed in items 12 and 13 for which reimbursement is requested.
Pefitloner has paid (or become obligated to pay) the following total amounts of the daimant's fees and expenses for which
reimbursement is requested.
(1) ~
~ Medical expenses listed in item 12: $
(2)
(3) ~ Attorney's fees induded in the total fee amount shown in item 13a:
Other expenses included in the total shown in item 13b:
$
$
Total: $ 0.00
(Attach pmofs of the fees snd expenses incunad snd the payments made or obligations lo pay incurred, e.ge bills or invoices,
canceled checks, cmdii card statements, expisnslions of benedts from insun.*rs, etc.)
15. tttet balance of proceeds for the claimant
The balance of the proceeds of the proposed settlement or judgment remaining for the daimant
after payment of all requested fess and expenses is: $ 30,000.00
16. SUMMARY
a. Gross amount of proceeds of settlement or judgment: $ 950,000.00
b. Medical expenses to be paid from proceeds of settlement
or judgment:
c. Attorney's fees to be paid from proceeds of settlement or
judgment:
d. Expenses (other than medical) to be paid from proceeds
of settlement or judgment:
e. Total fess and expenses to be paid from proceeds of settlement or
judgment (add (b), (c), snd (d)): ($ )
f. Balance of proceeds of settlement or judgment available for dsimant
after payment of all fees and expenses (subtract (e) fiom (a)): $ 30,000.00
MCSSS lRee. eever 1, 2020
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Peseeef1S
OR ACTION OR DISPOSITION OF PROCEEDS OF
dUDGMENT FOR MINOR OR PERSON WITH A DISABIUTY
CASE NAME: CASE NUMEEM
McKecee. et sl vs. Rsmos, M.D., st El 23CV00044
! !
17. Information about attorney representing or assisting petitioner
a. (1) ~ Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with
respect to the dsim asserted. (Skip the rest ofitem 17 and go to item 18.)
(2) ~s
asserted. Petitioner and the attorney ~
Petitioner has been represented or assisted by an attorney in preparing this pe5tion or with respect to the daim
do not
connsc5on with the daim giving ris to this petition.
~s do have an agreement for services provided in
(lf you answered sdo," attach a copy of the agreement as Affschment 17s, and complete items 170-17f)
b. The attorney who has represented or assisted petitioner is (name)i Edk L peters
{1) State Bsr number.155159
(2) Law "ml: Bcstwlck & Peterson, LLP
(3) Address: 591 Redwood Hwy Suite 2350
Mill Valley, CA 94941
(4) Telephone number. (415) 421-5300 (5) Email; erik bostwlcklirm.corn
c. The attorney ~s has not ~
has received attorney's fees or other compensation in addition to that requested in
this petition for services provided in connection with the daim giving rise to this petition. (If you answered "has, s identify the
person who paid the fees or other compenssdon, the amounts paid, snd the dates of payment):
From whom (names) Amounts Dates
~ Continued on Attachment 17c.
d. The attorney ~s did not did ~
become concerned with this matter, directly or indirectly, st the instance of a party
against whom the daim is asserted or a party's insurance canter. (If you answered "did,'xplain the circumstances in
Attachment 17d.)
e. The attorney ~s is not is ~
represenfing or employed by any other party or any insurance csmer involved
matter. (If you answered Ts,"identify the party or carrier and explain the mist(onship in Attachment 17e )
in the
f. The attorney ~
does not ~s does expect to receive attorney's fees or other compensation in addition to that
requested in this pefion for services provided in connection with the daim giving rise to this petition. (If you answered "does,"
identify the pemon who will pay the fees or other compensation, the amounts to be paid, snd the expected dates of payment)i
From whom (names) Amounts Exoscted dates
Hsylee McKecne $ 310,292.24
~ Continued on Attachment 17f.
MC000 tkss. Jssswy l, 202 ll Psssssf 00
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-350
CASE NAME: CASE NUMBER:
MBKsone, ei sl vs. Rsmos, M.D., st Bl 23CV00044
!
18. Disposition of balance for claimant (check either e or b, then check each option requested and enter emounl(s))i
a. ~ There Is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with
filed in (name of courl):
a disability
Case noz
~
(1) Petitioner requests that $ of the proceeds In money or other property be paid or delivered to the
guardian or the conservator of the estate. The money or other property is specified in Attachment 18a(1).
~
(2) Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability. Petitioner
requests authority to deposit or invest $ of the money or other property to be paid or delivered
under 18a(1) in insured accounts in one or more financial institutions in this state or with a trust company, subject to
withdrawal only on authorization of the court. The money or other property and the name, branch, and address of
each financial institution or trust company are specified in Attachment 18a(2).
(3) ~ Petitioner proposes that afi or a portion of the proceeds not become part of the guardianship or conservatorship
estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check all that apply):
(a) C]s to be deposited in insured accounts in one or more financial institutions in this state,
subject to withdrawal only on authorization of the courL The name, branch, and address of each depository are
spscNed in Attachment 18a(3)(a).
(b) ~$ to be invested in a single-premium deferred annuity subject to withdrawal only on
authorization of the court. The terms and conditions of the annuity are specified in Attachment 18a(3)(b).
(c) ~$ to be transferred to a custodian for the benefit of the minor under the California Uniform
Transfers to Minors Act The name and address of the proposed custodian and the property to be transferred are
specNed in Attachment 18a(3)(c).
(d) C]s to be transferred to the trustee of a trust that is either created by or approved in the order
approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of
age and contains all other terms and conditions determined to be necessary by the court to protect the minor's
interests. The terms of the proposed trust and the property to be Iransferred are speciTied in Attachment 18a(3)
(0)
~
C3$
(d).
A copy of the(proposed) judgment is attached as Attachment 3c.
to be transferred to the trustee of a special needs trust established under Probate Code
section 3604 for the beneilt of the minor or the adult person with a disability. The terms of the proposed spedal
needs trust and the property to be transferred are specified in Attachment 18a(3)(e).
b. ~P There is no guardianship or conservstorship of the estate of the claimant. Petitioner requests that the court order the
disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested):
(1) ~ A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed
and $ of money or other properly or both be paid or delivered to the person so appointed. The
money or other properly are specified in Attachment 18b(1).
(2) HS be deposited in insured accounts in one or more financial institubons in this state, subject to
withdrawal only on authorization of the court. The name, branch, and address of each depository are specNed in
Attachment 18b(2).
(3) ~J $ 30 000 00 be invested in a single-premium deferred annuity, subject to withdrawal only on authorization
of the court. The terms and conditions of the annuity are specified in Attachment 18b(3).
(4) C3 $ be paid or transferred to the trustee of a special needs trust established under Probate Code
section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs
trust and the money or other property to be paid or transferred are specified in Attachment 18b(4).
(5) Hs be paid or delivered to a parent of the minor, without bond, on the terms and under the
conditions specified in Probate Code sections 3401-3402. The name and address of the parent snd the money or
other property to be delivered are specified in Attachment 18b(6). (Value of minor's enlim estate, including the money
or property to be delivered, must not eirceed $ 5,000.)
(6) [ j $ be transferred to a custodian for the benefit of the minor under the California Uniform
Transfers to Minors Act. The name and address of the proposed custodian and the money or other property to be
transferred are specified in Attachment 18b(6).
uo250 IRev. Januay 1, 2021i P1BO 8 Pf 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIIW
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITI4 A DISABILITY
MC450
CASE NAME: CASE NUMBER:
McKeone, et al vg. Rgmcg, M.D., et El 23CV00044
!
18. Disposition of balance of proceeds of settlement or judgment (continued)
b. ~ There is no guardianship or conservatorship of the estate of the daimant. Petitioner requests that the court order the
disposNon of the balance of the proceeds of the setgement or judgment as follows (checff each option requested):
(T) C] $approving the settlementbeortransferred to the trustee of a trust that is either created by or approved in the order
judgment for the minor. This trust is revocable when the minor reaches 18 years sge,of
and contains all other tenne snd conditions determined to be necessary by the court to protect the minoris interests.
(8) ~$
~ The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 18b(7).
A copy of the (proposed) judgment is atlached as Attachment 3c.
of money be held on any conditions the court determines are in the best interest of the minor
or the adult person with a disability. The proposed conditions are specified on Attachment 18b(8). (Amount must not
exceed $20,000.)
(9) %$best interest of the minorof orproperty other than money be held on the conditions that the court determines are thein
the adult person with a disability. The proposed conditions and the properly are specified
In Attachment 18b(9).
(10) ~ $ be deposited with the county treasurer of the County of (name):
The deposit is authorized under and subject to the conditions specied in Probate Code section 3611(h).
(11)W $ be paid or delivered to the adult person with a disability. The money or other properly is
specified in Attachment 18b(11).
19. ~ Statutory liens for special needs trust
Petitioner requests an order for payment of funds to a special needs trust (explain how statutory liens under Pmbafe Code
section 3604, if any, will be satisfied):
~ Continued on Attachment 19.
20. ~ Additional orders
Petitioner requests the following additional orders (specify and explain):
~ Continued on Attachment 20.
MC400 iReu. Jaaualr 1. 2020 Page 0 ei10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
DocuSign Envelope ID: 08041 902-634FAB61-8497-E6COAED6A39B
CASE
NAME'cKecns.
et al va Rsmoc. M.D., et El
!
21. ~ I, the dslmant named In item 2,consent to ths order or Judgment requested In this peNlon.
(Required if the dsiment ic en adug rrith e dfaabiNy who has the cspscgy, under Pmbsle Code section 812, lo consent to the
orderortudgmsnr and does nol have a conselvslorof the estate. (see Prob. code, $ 3813J)
Oats:
22. Pegtlcnsr ~da
approval of the proposed compromise, seNsment, or dlsposiaon of Judgment proceeds to the court as fair,
reasonable, end In lhe beat interest of the chimant Peggonsr requests that the court appmvs this compromise, aeNement, or
diaposNon and make any other orders that ars just and reasonable.
23. Number of pages INached: 15
O I
. 2/22/2024
et4 r, retesA
8158EE4844C84EE ..
I dedare under penalty of perjury under ths laws of ths Stats of CaNomla Ihat ths foregoing Infonnagcn on this form and all
saachmenls is tnrs snd consct.
C848818848 87:
2/20/2024 jj4(,4
Oats:
77IJC5CA88444485..
Haylco R. McKsone and Lucsc MCKccne
dvlsoncsmrNANE0F Ernlonsu
84CEIC CN8 4444477 1. NIEO 88el 18 87 18
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
EXHIBIT 8
The underlying case involved negligent medical care and treatment to Petitioner and Claimant's
mother, Haylee McKeone, resulting in failure to timely diagnose and treat her breast cancer.
Minor claimant has a potential wrongful death claim.
Attachment 111(3)
The underlying case involved negligent medical care and treatment to Petitioner and Claimant's
mother, Haylee McKeone, resulting in failure to timely diagnose and treat her breast cancer.
Minor claimant has a potential wrongful death claim.
EXHIBIT 11b(6)
The underlying case involved negligent medical care and treatment to claimant's mother, Haylee
McKeone, resulting in failure to timely diagnose and treat her breast cancer. Minor claimant has
a potential wrongful death claim. Therefore, there are no medical reports for the minor claimant
to submit.
DacuS!Sn Bwdope ID: 0$$41$ltk6$4F4BSHI48lZSCSSEDSASSB
Oocoaeo EnvecPe IO: 88841 808884FA8848487~08ASO8A888
AUTHORIZATION AND AGREEMENT
Medical Malpractice
IT IS HEREBY AGREED by snd between the undersigned and the attorneys,
BOSTWICK & PETERSON. LLP:
1. Claims covered by Agreement Attorneys shall represent the undersigned
Haylee 84cxeone and Loons /4cKeone in prosecuting
a claim(s) for damages arising out of alleged medical malpractice that occurred
on or about 11/8/2021
This agreement does not cover other related chims that may arise and require
legal services, such as Trusts, counter claims, appeals, new trials, proceedings
to enforce a judgment, workers'ompensation daims, dient's disputes with
insurance camers regarding coverage or amount of loss or reimbursement for
benefits, or disputes with health care providers regarding an amount owed or
reimbursement for benefits provided, lf such matters arise and dient wishes
BOSTWICK & PETERSON, LLP to handle such matters, separate agreements
for legal services vtlll be required. In the event of an appeal, client(s) agree to
execute a separate attorney's fee cont/act with appellate counsel and to pay
appellate counsel's hourly fee.
2. COSTS AND EXPENSES: Client is responsible for all costs of li5gation and
attorneys at their discretion may advance costs incurred in the Investigation and
prosecution of said daim. Attorneys in their discretion may obtain the necessary
case costs by bomwing said costs from independent funding sources. If the
case expenses are funded through a loan, the interest rates will be itemized and
included as a litigation cost at the conclusion of the case. The costs and
expanses necessary in this case may include any or all of the following: case
evaluation fees, court filing fees, court reporters, process serving fees, fees to
private investigators, cost of obtaining records or other documents, fees to
photographers or graphic artists. fees to experts for consultation and/or for
appearance at depositions or trial, jury fees, mail, messenger and other delive/y
charges, parking end other local travel st 36.5If per mile, transportation, meals,
lodging and all other costs of necessary out-of-town travel, long distance
telephone charges, photocopying at 25If per page, facsimile at $ 2 per page, vord
processing charges, independent paralegel or medical/legal charges, interest
charges for advances of lifigation expenses, computerized legal research
charges, and other computer service time charges This list is not exclusive, and
other items may atso be necessary and included in a statement of costs and
expenses to be reimbursed. The rates shown are subject to change on prior
OOCuSgn Eweloys lo; ie041~S$144$T~NEOSA3$8
written no5ce to diect Costs shall not Include medical bills of dient. Client
recognizes that invoices from outside vendors may bs billed after a case has
been Nsolved and disbursed; such Invoices Nmain the responsibility of the
cment(s) and will bs sent direcgy to client(s) for payment.
3. CONTINGENCY FEE TO ATfORNEYS:
For Claims Flied Behre January 1, 2023:
Attorneys'ee for medical malpracgce daims are prescribed by the most recent
version of lhs California Business & Professions Code as follows:
{1) Forty percent (40%) of ths first gtty-thousand dollars ($60,000)
NcovsNd.
(2) Thirty-ohms and ons4hlrd percent (33-1f3%) of ths next glty-
thousand dollars ($ 50,000) recovered.
{3) Twsnty4tve percent {25%) of the next five hundred thousand
dollars ($ 500,000) recovered.
(4) Fifteen percent (15%) of any amount by which the recovery
exceeds six hundred thousand dollars ($600,000).
For Claims Filed On or After January 1,2023:
California Business & Professions Code caps atlomey's fees for dalms flied on
January 1, 20% as follows:
(1) Twenty4ive percent(25%) of recovery if segled before Sing a
comphitnt or arbllrsgon demand.
(2) Thlrty4uee percent {33%) of recovery ager Sing s complaint or
arbitration demand.
{3) Forty psnxint (40%) aller trial, if approved by the trial judge.
The undersigned agrees that this rate will apply and that it will be sepanriely
calculated from the tobd Ncovery fcr each individual dlent's share in each claim.
If there is a partial setdement and ths case proceeds as to other defendants, the
fee will be separately calculated for each stage of the case.
The rates set forth above are the mmdmum limits that may bs charged and Ihe
dlent hes a right to negotiat
Preview
CASE NAME: CASE NUMBER: McKeone, et al vs. Ramos, M.Du et al 23CV00044 ! 4. Incident or accident The incident or accident occurred as follows: a. Date and time: 11/8/21 b. Place: c. Persons involved (names): sussnne L Ramos, M.D., sussnne L Ramose, M.D., Inc. Bnd dalmant's mother, Haylee McKeone. ~ Continued on Attachment 4. 5. Nature of incident or accident The facts, events, snd circumstances of the incident or accident are (describe whet happened): Negligent medical cars and treatment of dement's mother, Haylee McKeons, resulted in failure to timely diagnose snd treat her breast cancer. Minor daimant hss a potential wrongful death daim. ~ Continued on Attachment 5. 6. Injuries The following injuries were sustained by the daimant as a result of the incident or accident (describ): Minor daimant has a potential wrongful death daim. ~ Continued on Attachment 6. 7. Treatment The daimant received the following care and treatment for the injuries described in item 6 fdescn'be): ~ Continued on Attachment 7. 8. Extent of injuries and recovery (An original or e photocopy of any doctor's report containing a diagnosis of fhs claimant's injun'es or s prognosis for the claimant's recovery, and a report of ihe cfaimant's cunenf condition, must be attached io this petition as Attachment 8. A new report is not necessary if a previous report accurately describes the claimant's current condition.$ a. ~ The daimant has recovered completely from the effects of the injuries described in item 6, and there are no permanent b. ~ injuries. Ths daimant hss not recovered completely from the effects of the injuries described in item 6, and the following injuries from which the daimant has not recovered are temporary (describe the remaining injunes and symptoms): c. ~ Continued on Attachment 8b. ~a The daimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries from which the daimant has not recovered are permanent (describe fhe permanent injuries snd symptoms): Minor daimant has a potential wrongful death claim. ~ Continued on Attachment 8c. MC000 tnau. January 1, 20211 00002af10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION DR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISASIUTY CASE NAME: CASE NUMBER McKecne, et sl 00. Rsmcs, M.D., et El 23CV00044 ! ! 9. ~e Petitioner has made a careful and diligent inquiry and investigation into the facts and circumstances of ths incident or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's Injuries. Pelltioner understands that It the compromise proposed in this petition is approved by the court and consummated, the claimant wffl never be able to recover any more compensation from the ssttgng defendants named below even if the claimant's injuries turn out to bs more serious than they now appear. 10. Amount and terms of settlement To settle the daim in item 3a or 3b, the defendants named below have offered to pay the following amounts to the dsimant: a. The total amount offered by all defendants named below is (specffy): $ 950,000.00 b. The defendants and amounts offered by each are as follows (specify): Defendants (names) Amounts Sussnne L. Rsmcs, M.D. End Sussnne L. Ramose, M.D., inc. $ 950,000.00 $ $ $ ~ Defendants and amounts offered continued on Atischment 10b. $ c. The terms of settlement are as follows (if the settlement is fo be paid in installments, both the lolsi amount snd the preseni value of the sefflemsnt must be indudsd): From the gross sealernent cf $950,000.00 for petitioner'0 medical mslprstice 0000, less sltcmeys feeS in the amount of $ 31 0,292.24, less case costs in the amount of $9,720.50, less cost reserve in Ihe amount of $ 1,00.00 leaving 0 net of $598,98727 to Petitioner with dsimant IC receive $ 30,000.00 for her potential wrcncful death Ecscn. ~ Continued on Attachment 10c. 11. a. ~ Settlement payments to others No defendant named in item 10b has offered to pay money to any person or persons other than the daimant to settle claims arising oul of the same incident or accident that resulted in ths claimant's injury. b. ~~ To setlle claims arising out of the same incident or accident that resulted in the claimant's injury, one or more defendants named in item 10b have also offered to pay money to a person or persons other than daimant. (1) {2) Petitioner ~e does not have ~ The total amount oifersd by all defendants to others is (specify): Gross mad r0sl Eealemenl $ hss a claim against the recovery of ths dsimant (other than for reimbursement of fees or expenses paid by petitioner and listed under item 14). 950,000.00 (if you answered Tres, explain in Affschmenl 1 fb(2) the circumslsnces and the effect your dsim hss on the pmposed (3) Petitioner ~ compmmise of the dsim described in this petition.) is not ~e Is a plaintiff in the same action with the claimant. (If you answered "is," explain in Attachment 1 f0(3) the drcumsfances and the effect your daim and ifs disposition has on the proposed compromise of the claim or scffon described in this pefffion.) (4) ~e Petitioner would receive money under the proposed setllement. {5) The settlement payments are to be apportioned and distributed as follows: Other olaintiffs or claimants (names) Amounts Peblicner Hsylse McKscns snd hsr husband Lucss McKecne $ 588,987.27 $ $ {6) ~ Additional plaintiffs or daimants and amounts are listed on Attachment 11b(5). $ Reasons for the apporbonmsnt of the set5sment payments between the claimant and each other plaintiff or daimant named above are specied in Attachment 11b(6). MC000INee. Jeeeeer 1,2021I Page 0 er 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS DF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY CASE NAME: CASE NUMBER: McKeone, et Bi vs. Rsmos, M.D., Bt Ei 23CV00044 ! 12. Ths claimant's medical expenses — Including medical expenses paid by petitioner, Medicare, Medi&st, and private insurers —to bs paid or reimbursed from proceeds of settlement or judgment s. Totals (1) Total medical expenses before any reductions: $ (2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): (3 ) (3) Total of negotiated, contractual, or statutory reductions, if any: ($ ) (4) Total medical expenses to be paid or reimbursed from the proceeds: $ 0.00 (5) Total amount of statutory or contractual liens, if any: $ b. Medical expenses were paid and sre to be reimbursed from the proceeds as follows: (1) ~ Paid by petiTioner in the amount of: (2) ~~ Paid by private health insurance or a self-funded plan under: ~ (s) ~ (b) An Employee Refiremsnt Income Security Act {ERISA) insured plan. An ERISA self-funded plan. ~ {c) (d) (e) A Non-ERISA insured plan. A Non-ERISA self-funded plan. Amount paid by plan: $ ~ (f) ~~ Amount of reimbursement to the plan from the proceeds of the settlement or judgment: (i) (ii) No reimbursement is requested by the plan. Reimbursement is to be made to the plan, and: ~ ~ (A) (S) (C) There is a contractual reduction of: There is a negotiated reduction of: No reducfion hss been agreed to, ($ ($ ). ), for a total reimbursement to the plan, in full satisfaction of its lien rights, in ths amount of: $ 0.00 (3) ~ PaidbyMedicareintheamountof: less the statutory reducfion in the amount of: for a total reimbursement to Medicare in the amount of: (ANsch a copy of the gnal Medicare demand letter or letter agreement as Attachment 120(3).) (4) ~~ (a) Paid by Medi-Cal in the amount of: $ Nofice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, ~~ (b) is attached ~ 5 14124.73.) A copy of the notice and proof of delivery: was filed in this case on (date): Notice of this daim or action has not been given to the Director of Health Care Senrices. (Explain why notice has ~ (c) not been given in Attachment 12b(4)(b).) In full satisfacfion of its lian rights, Medi-Cal has agreed to accept mimbursement in the amount of: $ (Attach s copy of the gnat Medi-Cal demand letter or letter agreement as Attachment 12b(4)(c).) ~ (d) Petitioner is entitled to s reduction of the Medi-Cal lien under Welfare and Institutions Code section 14124.76 and ~ ~ (i) (ii) (check one): Is filing a motion seeking a reduction of the lien concurrently with this petition. Requests that the court reserve jurisdiction over this issue. The amount of the lien in dispute is: $ ~ ~ (5) (a) (i) (ii) There are no statutory or contractual liens for payment of daimant's medical expenses. There are one or more statutory or contractual liens of medical service providers for payment of claimant's medical expenses. The total amount claimed under these liens is: $ In full satisfaction of their lien daims, the lienholders have agreed to accept the sum of: $ (Pmvlde requestedinformsllon for each lienholder end other specllied medical service pmvlders on next page.) MC0% IRfe. Jaeeafr 1, 2021i Page 4 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: CASE NUMEElt McKeone, et ai vg. Ramcg, M.D., et ai 23CV00044 ! ! 12. Claimant's medical expenses (continued) b. (5) {b) Thenameofeachmedicalserviceproviderthatfumishedcare andtrestmenttoclaimantand(1)hase lienforallor any part of the charges or (2) was paid (or will bs paid from ths proceeds) by petitioner, for which payment petitioner requests reimbursement; the amounts charged and paid„ the amount of negotiated reductions of charges, if any; and the amount to bs paid from the proceeds of the settlement or judgment to each provider are as follows: (i) (A) Provider(name) (8) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): ($ (E) Negotiated reducbon, if any: ($ (F) Amount to be paid from proceeds of settlement or judgment: $ (li) (A) Provider (name): (8) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): ($ (E) Negotiated reducbon, if any: ($ (F) Amount to be paid from proceeds of settlement or judgment: $ (iii) (A)Provider (name): (8) Address: (C) Amountcharged: $ (D) Amount paid (whether or not by insurance): {$ (E) Negotiated reduction, if any: ($ (F) Amount to be paid from proceeds of settlement or judgment: ~ $ Continued on Attachment 12b(5). (Provide information about additional pfoviderg in the above format, including provlderg paid or to be paid by pelltioner, for which payment reimbursement is requested in item 12b(1), above. You mey use form MC-350(A-12b(5)j for this purpose.) 13. Claimant's attorney's fees and ag other expenses (except for medical expenses), including expenses advanced by daimant's attorney or paid or incurred by petitioner, to be reimbursed from proceeds of settlement or judgment a. Total amount of attorney's fees for which court approval is requested: $ (ff fees are requested, attach ss Altschment 13e s declaration from the attorney explaining the basis for the request, including a discussion of applicable factors listed in rule 7.955(b) of the Cel. Rules of Coun. Respond to item 17e(2) on page 7 and attach a copy of any written attorney fee agreement ss Attachment 17a J b. The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted from ths incident or accident, and should be paid out of claimant's share of the proceeds of the settlement or judgment: Items Pavees lnamesi Amounts $ $ $ $ $ $ $ ~ Continued on Attachment 13b. $ Totah $ 0.00 MC400 [Rae. Jaeovy 1, 2021i Page 0 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE CASE NUMBER NAME.'CKsone, et al vs. Rsmos, tet.t3., et Bl 23CV00044 ! ! 14. a. b. ~ Reimbursement of fees and expenses paid by petitioner ~ Petitioner has paid none of the fees or expenses listed in items 12 and 13 for which reimbursement is requested. Pefitloner has paid (or become obligated to pay) the following total amounts of the daimant's fees and expenses for which reimbursement is requested. (1) ~ ~ Medical expenses listed in item 12: $ (2) (3) ~ Attorney's fees induded in the total fee amount shown in item 13a: Other expenses included in the total shown in item 13b: $ $ Total: $ 0.00 (Attach pmofs of the fees snd expenses incunad snd the payments made or obligations lo pay incurred, e.ge bills or invoices, canceled checks, cmdii card statements, expisnslions of benedts from insun.*rs, etc.) 15. tttet balance of proceeds for the claimant The balance of the proceeds of the proposed settlement or judgment remaining for the daimant after payment of all requested fess and expenses is: $ 30,000.00 16. SUMMARY a. Gross amount of proceeds of settlement or judgment: $ 950,000.00 b. Medical expenses to be paid from proceeds of settlement or judgment: c. Attorney's fees to be paid from proceeds of settlement or judgment: d. Expenses (other than medical) to be paid from proceeds of settlement or judgment: e. Total fess and expenses to be paid from proceeds of settlement or judgment (add (b), (c), snd (d)): ($ ) f. Balance of proceeds of settlement or judgment available for dsimant after payment of all fees and expenses (subtract (e) fiom (a)): $ 30,000.00 MCSSS lRee. eever 1, 2020 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Peseeef1S OR ACTION OR DISPOSITION OF PROCEEDS OF dUDGMENT FOR MINOR OR PERSON WITH A DISABIUTY CASE NAME: CASE NUMEEM McKecee. et sl vs. Rsmos, M.D., st El 23CV00044 ! ! 17. Information about attorney representing or assisting petitioner a. (1) ~ Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with respect to the dsim asserted. (Skip the rest ofitem 17 and go to item 18.) (2) ~s asserted. Petitioner and the attorney ~ Petitioner has been represented or assisted by an attorney in preparing this pe5tion or with respect to the daim do not connsc5on with the daim giving ris to this petition. ~s do have an agreement for services provided in (lf you answered sdo," attach a copy of the agreement as Affschment 17s, and complete items 170-17f) b. The attorney who has represented or assisted petitioner is (name)i Edk L peters {1) State Bsr number.155159 (2) Law "ml: Bcstwlck & Peterson, LLP (3) Address: 591 Redwood Hwy Suite 2350 Mill Valley, CA 94941 (4) Telephone number. (415) 421-5300 (5) Email; erik bostwlcklirm.corn c. The attorney ~s has not ~ has received attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the daim giving rise to this petition. (If you answered "has, s identify the person who paid the fees or other compenssdon, the amounts paid, snd the dates of payment): From whom (names) Amounts Dates ~ Continued on Attachment 17c. d. The attorney ~s did not did ~ become concerned with this matter, directly or indirectly, st the instance of a party against whom the daim is asserted or a party's insurance canter. (If you answered "did,'xplain the circumstances in Attachment 17d.) e. The attorney ~s is not is ~ represenfing or employed by any other party or any insurance csmer involved matter. (If you answered Ts,"identify the party or carrier and explain the mist(onship in Attachment 17e ) in the f. The attorney ~ does not ~s does expect to receive attorney's fees or other compensation in addition to that requested in this pefion for services provided in connection with the daim giving rise to this petition. (If you answered "does," identify the pemon who will pay the fees or other compensation, the amounts to be paid, snd the expected dates of payment)i From whom (names) Amounts Exoscted dates Hsylee McKecne $ 310,292.24 ~ Continued on Attachment 17f. MC000 tkss. Jssswy l, 202 ll Psssssf 00 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: CASE NUMBER: MBKsone, ei sl vs. Rsmos, M.D., st Bl 23CV00044 ! 18. Disposition of balance for claimant (check either e or b, then check each option requested and enter emounl(s))i a. ~ There Is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with filed in (name of courl): a disability Case noz ~ (1) Petitioner requests that $ of the proceeds In money or other property be paid or delivered to the guardian or the conservator of the estate. The money or other property is specified in Attachment 18a(1). ~ (2) Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability. Petitioner requests authority to deposit or invest $ of the money or other property to be paid or delivered under 18a(1) in insured accounts in one or more financial institutions in this state or with a trust company, subject to withdrawal only on authorization of the court. The money or other property and the name, branch, and address of each financial institution or trust company are specified in Attachment 18a(2). (3) ~ Petitioner proposes that afi or a portion of the proceeds not become part of the guardianship or conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check all that apply): (a) C]s to be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the courL The name, branch, and address of each depository are spscNed in Attachment 18a(3)(a). (b) ~$ to be invested in a single-premium deferred annuity subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 18a(3)(b). (c) ~$ to be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act The name and address of the proposed custodian and the property to be transferred are specNed in Attachment 18a(3)(c). (d) C]s to be transferred to the trustee of a trust that is either created by or approved in the order approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the property to be Iransferred are speciTied in Attachment 18a(3) (0) ~ C3$ (d). A copy of the(proposed) judgment is attached as Attachment 3c. to be transferred to the trustee of a special needs trust established under Probate Code section 3604 for the beneilt of the minor or the adult person with a disability. The terms of the proposed spedal needs trust and the property to be transferred are specified in Attachment 18a(3)(e). b. ~P There is no guardianship or conservstorship of the estate of the claimant. Petitioner requests that the court order the disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested): (1) ~ A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed and $ of money or other properly or both be paid or delivered to the person so appointed. The money or other properly are specified in Attachment 18b(1). (2) HS be deposited in insured accounts in one or more financial institubons in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specNed in Attachment 18b(2). (3) ~J $ 30 000 00 be invested in a single-premium deferred annuity, subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 18b(3). (4) C3 $ be paid or transferred to the trustee of a special needs trust established under Probate Code section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust and the money or other property to be paid or transferred are specified in Attachment 18b(4). (5) Hs be paid or delivered to a parent of the minor, without bond, on the terms and under the conditions specified in Probate Code sections 3401-3402. The name and address of the parent snd the money or other property to be delivered are specified in Attachment 18b(6). (Value of minor's enlim estate, including the money or property to be delivered, must not eirceed $ 5,000.) (6) [ j $ be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred are specified in Attachment 18b(6). uo250 IRev. Januay 1, 2021i P1BO 8 Pf 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIIW OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITI4 A DISABILITY MC450 CASE NAME: CASE NUMBER: McKeone, et al vg. Rgmcg, M.D., et El 23CV00044 ! 18. Disposition of balance of proceeds of settlement or judgment (continued) b. ~ There is no guardianship or conservatorship of the estate of the daimant. Petitioner requests that the court order the disposNon of the balance of the proceeds of the setgement or judgment as follows (checff each option requested): (T) C] $approving the settlementbeortransferred to the trustee of a trust that is either created by or approved in the order judgment for the minor. This trust is revocable when the minor reaches 18 years sge,of and contains all other tenne snd conditions determined to be necessary by the court to protect the minoris interests. (8) ~$ ~ The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 18b(7). A copy of the (proposed) judgment is atlached as Attachment 3c. of money be held on any conditions the court determines are in the best interest of the minor or the adult person with a disability. The proposed conditions are specified on Attachment 18b(8). (Amount must not exceed $20,000.) (9) %$best interest of the minorof orproperty other than money be held on the conditions that the court determines are thein the adult person with a disability. The proposed conditions and the properly are specified In Attachment 18b(9). (10) ~ $ be deposited with the county treasurer of the County of (name): The deposit is authorized under and subject to the conditions specied in Probate Code section 3611(h). (11)W $ be paid or delivered to the adult person with a disability. The money or other properly is specified in Attachment 18b(11). 19. ~ Statutory liens for special needs trust Petitioner requests an order for payment of funds to a special needs trust (explain how statutory liens under Pmbafe Code section 3604, if any, will be satisfied): ~ Continued on Attachment 19. 20. ~ Additional orders Petitioner requests the following additional orders (specify and explain): ~ Continued on Attachment 20. MC400 iReu. Jaaualr 1. 2020 Page 0 ei10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY DocuSign Envelope ID: 08041 902-634FAB61-8497-E6COAED6A39B CASE NAME'cKecns. et al va Rsmoc. M.D., et El ! 21. ~ I, the dslmant named In item 2,consent to ths order or Judgment requested In this peNlon. (Required if the dsiment ic en adug rrith e dfaabiNy who has the cspscgy, under Pmbsle Code section 812, lo consent to the orderortudgmsnr and does nol have a conselvslorof the estate. (see Prob. code, $ 3813J) Oats: 22. Pegtlcnsr ~da approval of the proposed compromise, seNsment, or dlsposiaon of Judgment proceeds to the court as fair, reasonable, end In lhe beat interest of the chimant Peggonsr requests that the court appmvs this compromise, aeNement, or diaposNon and make any other orders that ars just and reasonable. 23. Number of pages INached: 15 O I . 2/22/2024 et4 r, retesA 8158EE4844C84EE .. I dedare under penalty of perjury under ths laws of ths Stats of CaNomla Ihat ths foregoing Infonnagcn on this form and all saachmenls is tnrs snd consct. C848818848 87: 2/20/2024 jj4(,4 Oats: 77IJC5CA88444485.. Haylco R. McKsone and Lucsc MCKccne dvlsoncsmrNANE0F Ernlonsu 84CEIC CN8 4444477 1. NIEO 88el 18 87 18 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY EXHIBIT 8 The underlying case involved negligent medical care and treatment to Petitioner and Claimant's mother, Haylee McKeone, resulting in failure to timely diagnose and treat her breast cancer. Minor claimant has a potential wrongful death claim. Attachment 111(3) The underlying case involved negligent medical care and treatment to Petitioner and Claimant's mother, Haylee McKeone, resulting in failure to timely diagnose and treat her breast cancer. Minor claimant has a potential wrongful death claim. EXHIBIT 11b(6) The underlying case involved negligent medical care and treatment to claimant's mother, Haylee McKeone, resulting in failure to timely diagnose and treat her breast cancer. Minor claimant has a potential wrongful death claim. Therefore, there are no medical reports for the minor claimant to submit. DacuS!Sn Bwdope ID: 0$$41$ltk6$4F4BSHI48lZSCSSEDSASSB Oocoaeo EnvecPe IO: 88841 808884FA8848487~08ASO8A888 AUTHORIZATION AND AGREEMENT Medical Malpractice IT IS HEREBY AGREED by snd between the undersigned and the attorneys, BOSTWICK & PETERSON. LLP: 1. Claims covered by Agreement Attorneys shall represent the undersigned Haylee 84cxeone and Loons /4cKeone in prosecuting a claim(s) for damages arising out of alleged medical malpractice that occurred on or about 11/8/2021 This agreement does not cover other related chims that may arise and require legal services, such as Trusts, counter claims, appeals, new trials, proceedings to enforce a judgment, workers'ompensation daims, dient's disputes with insurance camers regarding coverage or amount of loss or reimbursement for benefits, or disputes with health care providers regarding an amount owed or reimbursement for benefits provided, lf such matters arise and dient wishes BOSTWICK & PETERSON, LLP to handle such matters, separate agreements for legal services vtlll be required. In the event of an appeal, client(s) agree to execute a separate attorney's fee cont/act with appellate counsel and to pay appellate counsel's hourly fee. 2. COSTS AND EXPENSES: Client is responsible for all costs of li5gation and attorneys at their discretion may advance costs incurred in the Investigation and prosecution of said daim. Attorneys in their discretion may obtain the necessary case costs by bomwing said costs from independent funding sources. If the case expenses are funded through a loan, the interest rates will be itemized and included as a litigation cost at the conclusion of the case. The costs and expanses necessary in this case may include any or all of the following: case evaluation fees, court filing fees, court reporters, process serving fees, fees to private investigators, cost of obtaining records or other documents, fees to photographers or graphic artists. fees to experts for consultation and/or for appearance at depositions or trial, jury fees, mail, messenger and other delive/y charges, parking end other local travel st 36.5If per mile, transportation, meals, lodging and all other costs of necessary out-of-town travel, long distance telephone charges, photocopying at 25If per page, facsimile at $ 2 per page, vord processing charges, independent paralegel or medical/legal charges, interest charges for advances of lifigation expenses, computerized legal research charges, and other computer service time charges This list is not exclusive, and other items may atso be necessary and included in a statement of costs and expenses to be reimbursed. The rates shown are subject to change on prior OOCuSgn Eweloys lo; ie041~S$144$T~NEOSA3$8 written no5ce to diect Costs shall not Include medical bills of dient. Client recognizes that invoices from outside vendors may bs billed after a case has been Nsolved and disbursed; such Invoices Nmain the responsibility of the cment(s) and will bs sent direcgy to client(s) for payment. 3. CONTINGENCY FEE TO ATfORNEYS: For Claims Flied Behre January 1, 2023: Attorneys'ee for medical malpracgce daims are prescribed by the most recent version of lhs California Business & Professions Code as follows: {1) Forty percent (40%) of ths first gtty-thousand dollars ($60,000) NcovsNd. (2) Thirty-ohms and ons4hlrd percent (33-1f3%) of ths next glty- thousand dollars ($ 50,000) recovered. {3) Twsnty4tve percent {25%) of the next five hundred thousand dollars ($ 500,000) recovered. (4) Fifteen percent (15%) of any amount by which the recovery exceeds six hundred thousand dollars ($600,000). For Claims Filed On or After January 1,2023: California Business & Professions Code caps atlomey's fees for dalms flied on January 1, 20% as follows: (1) Twenty4ive percent(25%) of recovery if segled before Sing a comphitnt or arbllrsgon demand. (2) Thlrty4uee percent {33%) of recovery ager Sing s complaint or arbitration demand. {3) Forty psnxint (40%) aller trial, if approved by the trial judge. The undersigned agrees that this rate will apply and that it will be sepanriely calculated from the tobd Ncovery fcr each individual dlent's share in each claim. If there is a partial setdement and ths case proceeds as to other defendants, the fee will be separately calculated for each stage of the case. The rates set forth above are the mmdmum limits that may bs charged and Ihe dlent hes a right to negotiat