Exhibit 10.35

 

EXECUTION VERSION

 

CAUSE NO. 2015-24531

 

JOSHUA KEEL INDIVIDUALLY

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IN THE DISTRICT COURT OF

AND AS NEXT FRIEND OF

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MINORS E.K. AND V.K.

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Plaintiff

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v.

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DEVON ENERGY CORPORATION,

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HARRIS COUNTY, TEXAS

DEVON ENERGY PRODUCTION

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COMPANY, LP., DEVON

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INTERNATIONAL, LTD., WEATHERFORD

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INTERNATIONAL, LLC, HELMERICH &

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PAYNE, INC., HELMERICH & PAYNE

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INTERNATIONAL DRILLING CO., AND

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WAYNE DUNCAN, LLC

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Defendants

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152nd JUDICIAL DISTRICT

 

CONFIDENTIAL SETTLEMENT

AGREEMENT AND GENERAL RELEASE OF CLAIMS

 

This Confidential Settlement Agreement and General Release of Claims
(collectively, this “Settlement Agreement”) is entered into as of October   ,
2016, by and between Joshua Keel (individually and through his guardian ad litem
Donna Roth), and as next friend of minors Erin Keel and Veda Keel, and Erin Keel
and Veda Keel, individually and through their guardian ad litem Ana Hernandez
(collectively, “Plaintiffs”); Helmerich & Payne, Inc., and Helmerich & Payne
International Drilling Co. (jointly, the “H&P Defendants”); and Devon Energy
Corporation, Devon Energy Production Company, L.P., Devon International, Ltd.,
Weatherford International LLC, Wayne Duncan, LLC, Battle Energy Services, LLC,
Fuson Industrial Maintenance, LLC, Jolley, Castillo, Drennon, LP d/b/a Sierra
Engineering, LLC, Man Welding Services, Inc., GSM Consulting Inc. d/b/a GSM,
Inc., and Jeff Lajoie (collectively, the “non-H&P Defendants,” and, with the H&P
Defendants, collectively, the “Defendants”) and intervenor New Hampshire
Insurance Company (“Intervenor”).  Ryan Gonzales, Worldwide Safety and Security,
LLC, Jaime’s Welding LLC, Roy Saenz, Kenny Allen, Boyd Hightower, and Jon
Holmquist are non-parties whom Plaintiffs agree to release (collectively, the
“Non-Party Releasees”).  Plaintiffs and Defendants are each referred to herein
individually as a “Party” and collectively as the “Parties.”

 

WHEREAS, on July 11, 2014, Plaintiff Joshua Keel was injured while working on
Rig 223 in Eddy County, New Mexico;

 

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EXECUTION VERSION

 

WHEREAS, on April 28, 2015, Plaintiffs filed a lawsuit styled Keel, et al. v.
Devon Energy Corp., et al., No. 2015-24531 in the 152nd Judicial District Court
of Harris County, Texas (the “Lawsuit”), seeking relief related to injuries
suffered by Plaintiff Joshua Keel on July 11, 2014;

 

WHEREAS, on August 18, 2016, Helmerich & Payne International Drilling Co. filed
a declaratory judgment action, cause no. 2016-55153, in the 334th District Court
of Harris County, Texas, seeking declaration of insurance coverage related to
the Lawsuit, and certain of the non-H&P Defendants filed answers and cross
and/or counter-claims in response thereto (the “Declaratory Action”);

 

WHEREAS, solely to avoid the costs and expenses of resolving the Lawsuit and any
associated or contemplated litigation, including, but not limited to, the
Declaratory Action (collectively, the “Dispute”), and without any Party
acknowledging fault or liability, the Parties desire to compromise and settle
the Dispute and all of the disputes and controversies arising from or related to
the Dispute, including, but not limited to, all claims, counterclaims, or
third-party claims asserted, or that could have been asserted, by the Parties in
any litigation, and/or any claims for attorneys’ fees, interest, or costs that
have been or could have been asserted by the Parties in any litigation; and

 

WHEREAS the Parties intend that all Parties are to keep this Settlement
Agreement strictly private and confidential, except as required by law,
including but not limited to the disclosure requirements of a public company.

 

NOW THEREFORE, in consideration of the mutual promises and releases contained
herein, the receipt of which is hereby acknowledged, the Parties intending to be
legally bound hereby covenant and agree as follows:

 

1.                                      The above recitals are hereby
incorporated in full by reference.

 

2.                                      Settlement Payment.  On behalf of all
Defendants, and in full satisfaction of any and all claims of the Parties (as
stated in Paragraph 15), within sixty days of the “Effective Date” (as defined
in Paragraph 6) of this Agreement, and in exchange for fully executed settlement
documents setting forth the terms of settlement approved by the Court, Helmerich
& Payne Inc. and/or its insurers and/or its underwriters shall pay or cause to
be paid amounts with a total present value of SEVENTY-TWO MILLION DOLLARS AND
ZERO CENTS ($72,000,000.00) (the “Settlement Payment”) under the terms and
conditions set forth in the attached Exhibit “A” which forms a part of and is
incorporated into this Settlement Agreement, as if fully set out herein.

 

Of the amount of the Settlement Payment reflected above, $68,000,000.00 is being
paid to Joshua Keel, and $2,000,000.00 is being paid to each of his minor
children, i.e. $2,000,000.00 to Erin Keel and $2,000,000.00 Veda Keel.  All sums
set forth herein constitute damages on account of personal injuries or sickness,
within the meaning of Section 104(a)(1)-(2) of the Internal Revenue Code of
1986, as amended.

 

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EXECUTION VERSION

 

3.                                      Tax Liability.  Plaintiffs shall have
sole responsibility for any and all taxes, if any, related to the Settlement
Payment.  The Parties make no representations as to the tax treatment or legal
effect of the Settlement Payment called for hereunder, and Plaintiffs are not
relying on any statement or representation by the Defendants and/or Intervenor
in this regard. Plaintiffs understand and agree that they will be responsible
for the payment of any and all taxes and penalties assessed on the payments
described herein and will hold the Defendants and/or Intervenor free and
harmless from and against any claims resulting from treatment of such payments,
including the treatment of such payments as not subject to withholding or
deduction for payroll and employment taxes.

 

4.                                      Circular 230 Disclaimer.  Each Party to
this Agreement (for purposes of this section, the “acknowledging party” and each
Party to this Agreement other than the acknowledging party, an “other party”)
acknowledges and agrees that (1) no provision of this Agreement, and no written
communication or disclosure between or among the Parties or their attorneys and
other advisers, is or was intended to be, nor shall any such communication or
disclosure constitute or be construed or be relied upon as, tax advice within
the meaning of United States Treasury Department circular 230 (31 C.F.R part 10,
as amended); (2) the acknowledging party (a) has relied exclusively upon his,
her, or its own, independent legal and tax counsel for advice (including tax
advice) in connection with this Agreement, (b) has not entered into this
Agreement based upon the recommendation of any other party or any attorney or
advisor to any other party, and (c) is not entitled to rely upon any
communication or disclosure by any attorney or adviser to any other party to
avoid any tax penalty that may be imposed on the acknowledging party; and (3) no
attorney or adviser to any other party has imposed any limitation that protects
the confidentiality of any such attorney’s or adviser’s tax strategies
(regardless of whether such limitation is legally binding) upon disclosure by
the acknowledging party of the tax treatment or tax structure of any
transaction, including any transaction contemplated by this Agreement.

 

5.                                      Appointment of Guardian Ad Litems.  The
Parties agree that it is appropriate that the Court has appointed guardians ad
litem for the Plaintiffs, one for Joshua Keel and one for his two minor
children, to review this Settlement Agreement, and to determine if the
settlement is in the Plaintiffs’ best interests.  The Parties further agree to
present this Settlement Agreement for court approval at a hearing to prove up
the reasonableness and fairness of the Settlement Agreement (the “Settlement
Hearing”).  The Parties shall endeavor in good faith to schedule the Settlement
Hearing with the 152nd Judicial District Court in Harris County, Texas prior to
October 24, 2016, pending the court’s availability.

 

6.                                      Effective Date.  The Effective Date
shall be the date on which the Court approves this fully-executed Agreement as
set forth in Paragraph 5.

 

7.                                      Agreed Motion for Dismissal of Lawsuit
with Prejudice.  Within two business days of receipt of the Settlement Payment,
Plaintiffs shall direct their counsel to execute and file an Agreed Motion for
Dismissal of Lawsuit with Prejudice and make good faith efforts to timely obtain
an Order of Dismissal with prejudice from the court in the Lawsuit within five
business days.  The “Dismissal Date” will be the date on which the Order of
Dismissal is Granted by the Court.

 

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EXECUTION VERSION

 

8.                                      Agreed Motion for Dismissal of
Declaratory Action.  Within five business days of the court granting the Agreed
Motion for Dismissal of Lawsuit with Prejudice in the Lawsuit as provided in
Paragraph 7, Helmerich & Payne International Drilling Co. and the non-H&P
Defendants in the Declaratory Action will file an Agreed Motion for Dismissal of
the Declaratory Action with Prejudice, and these parties shall make good faith
efforts to timely obtain a dismissal of the Declaratory Judgment with prejudice.

 

9.                                      Workers’ Compensation Lien for Past
Workers’ Compensation Benefits Waived as of Effective Date.  As of the Effective
Date, the existing workers’ compensation lien for any workers’ compensation
medical and indemnity benefits paid to or on behalf of Joshua Keel on or before
the Effective Date shall be waived and extinguished.  Provided, however, that
this Settlement Agreement is not intended to cover and does not apply to
Plaintiff Joshua Keel’s rights, if any, to pursue available workers’
compensation benefits, if any, in the future.  Any rights Plaintiffs may have
after the Effective Date with respect to future workers’ compensation benefits
will be controlled and governed by the law of New Mexico.

 

10.                               Medicare Set-Aside.  The Parties hereby
acknowledge the following: (1) Under the Medicare Secondary Payer (“MSP”)
statute, 42 U.S.C. §1395y(b), and its accompanying regulations (“the MSP
Provisions”), the Centers for Medicare and Medicaid Services (the “CMS”) in
certain circumstances may have an obligation to seek reimbursement of
conditional payments made by the Medicare program (Title XVIII of the Social
Security Act) (the “Medicare Program”) on claims for items and services relating
to injuries allegedly sustained by Plaintiff Joshua Keel; (2) Plaintiff and his
counsel are in the best position to determine if any reimbursement obligation
currently exists, based on Plaintiff’s entitlement (or lack thereof) to Medicare
Program benefits, Plaintiff’s actual receipt of such benefits, and, if there is
a reimbursement obligation, to ensure that the Medicare Program’s interests are
properly considered and discharged; (3) If there is a reimbursement obligation
to the Medicare Program, Plaintiff is responsible under the MSP Provisions to
verify, resolve and satisfy such obligation and provide Defendants with a copy
of any Medicare final demand and lien satisfaction letter showing satisfaction
of any pre-settlement conditional liens; and (4) if Plaintiff is now or in the
past has been enrolled in the Medicare Program, a H&P Defendant will report this
Agreement to the CMS pursuant to the MSP Provisions (even if the H&P Defendant
does not agree that the evidence actually establishes liability for injuries
allegedly sustained by Plaintiff).

 

Plaintiff Keel represents and warrants that he and Plaintiff Keel’s counsel have
reviewed the underlying facts and evidence of this case.  Plaintiff Keel
understands and acknowledges that if Plaintiff is Medicare-enrolled at the time
of settlement, a H&P Defendant is required to report this Agreement to the CMS
but further acknowledges that by doing so, the H&P Defendant does not concede or
admit that it necessarily agrees that any H&P Defendant is liable for any
alleged injuries.

 

Plaintiff Keel also represents and warrants that, if Plaintiff Keel has not
already reimbursed or otherwise satisfied the Medicare Program for conditional
payments made on claims for items and services relating to the injuries that are
the subject of the action being resolved by this Agreement, Plaintiff Keel will
do so in a timely manner as set forth in the MSP Provisions.

 

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EXECUTION VERSION

 

Plaintiff Keel further represents and warrants that, to the extent any other
government payer (including but not limited to Masshealth, Medicaid, Veteran’s
Administration, Tricare/CHAMPUS) has a right to be reimbursed for any payments
made on claims for items and services relating to the alleged injuries that are
the subject of this action being resolved by this Agreement, Plaintiff Keel has,
or will, fully reimburse, resolve, or otherwise satisfy such payers.

 

Plaintiff Keel acknowledges that in making payment pursuant to this Agreement,
the H&P Defendants are reasonably relying on the representation and warranties
made by Plaintiff Keel herein and these representations and warranties are a
material inducement to Helmerich & Payne, Inc. to make payment as part of this
Agreement.

 

The parties have agreed to properly consider Medicare’s interests as secondary
payer under the Medicare Secondary Payer Act, as set forth above.  Plaintiff
Keel represents and warrants that, to the best of all parties’ knowledge,
Plaintiff Keel is not enrolled in the Medicare program as of the date of
settlement.

 

However, given the “reasonable expectation” of Medicare eligibility, Plaintiff
and his counsel have secured and have agreed to establish a Medicare Set-Aside
(“MSA”) under the terms and conditions of attached Exhibit B.  The attached
Medicare Set-Aside Exhibit B, provided by Shapiro Settlement Solutions and to be
funded from the Plaintiff’s settlement proceeds, as set forth in Exhibit A,
calls for $1,985,596.30 to be set-aside and utilized for future
Medicare-allowable, claim-related medical expenses. The MSA is to be established
and administered by Plaintiff or his trustee.  Defendants will not be involved
in the administration of the MSA.

 

PLAINTIFF AGREES TO INDEMNIFY AND/OR HOLD HARMLESS AND DEFEND DEFENDANTS FROM
ANY CAUSE OF ACTION, INCLUDING, BUT NOT LIMITED TO ANY LOSS OF MEDICARE OR
SOCIAL SECURITY BENEFITS, OR ANY RECOVERY FROM THE CENTERS FOR MEDICARE AND
MEDICAID SERVICES, THE MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR, THE
BENEFITS COORDINATION & RECOVERY CENTER, OR ANY OTHER MEDICARE AGENCY OR
MEDICARE ADVANTAGE PLAN MAY PURSUE, INCLUDING ANY RECOVERY SOUGHT BY MEDICARE
FOR PAST, PRESENT OR FUTURE LIENS.  Plaintiff also specifically agrees to
release any claim or right to bring any possible future action under the MSP
against Released Parties, including, but not limited to any cause of action
under 42 U.S.C. §1395y(b)(3)(A).  Should Medicare require that it be reimbursed
for any medical expenses for which it has paid, Plaintiff agrees to be
responsible for the same.

 

Plaintiff has been given opportunity to seek assistance from legal counsel of
his choosing and/or directly from the Social Security Administration or other
governmental entity regarding any impact this Release may have on current or
future eligibility for governmental benefits.

 

11.                               Structured Settlement.  Amounts to be
structured, as set out in Exhibit A, shall be co-brokered with Atlas Settlement
Group and Scott Freeman of Settlement Alliance.  Should AIG proceeds be utilized
for such a structured settlement, an AIG-approved life market will be utilized
for the portion of the settlement funded by AIG.  Additional detail regarding
the distribution of the settlement funds outlined in this Agreement is provided
in Exhibit A which is attached and incorporated by reference.

 

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EXECUTION VERSION

 

12.                               Acknowledgement of Mutual Compromise and
Valuable Consideration.  The Parties hereby acknowledge and agree that the
exchange set forth in this Settlement Agreement reflects a mutual compromise and
constitutes an exchange of valuable consideration.  All Parties agree that this
is a material inducement to each of the Parties entering into this Settlement
Agreement.

 

13.                               Attorneys’ Fees, Expenses, and Costs.  The
Parties agree that each Party shall be solely responsible for its own litigation
costs and fees, attorneys’ fees, expenses, and other costs incurred in
connection with the Dispute, this Settlement Agreement, and any future disputes
between each of the Defendants and the Plaintiffs, and the Intervenor and the
Plaintiffs.  But the H&P Defendants shall bear the responsibility of paying
reasonable guardian ad litem fees for Plaintiffs; provided, however, that
nothing in this Agreement is intended to, nor does it, extinguish the rights of
the non-H&P Defendants to seek direct payment and/or reimbursement from the H&P
Defendants of defense costs, including attorneys’ fees, expert witness and
consultant fees, costs, and expenses, related to the Lawsuit.

 

14.                               No Other Payment or Compensation Due.  The
Parties agree that the Settlement Payment shall exhaust and fully satisfy any
debts or liabilities related to the Dispute.  Except as provided in Paragraph
13, the Parties further agree that the Parties and any of their past, present,
and future principals, officers, directors, managers, partners, shareholders,
stockholders, members, employees, parent companies, subsidiaries, affiliates,
associated companies, agents, contractors, consultants, attorneys, trustees,
trusts, trustors, settlors, investors, accountants, insurers, reinsurers,
underwriters, predecessors, successors, assigns, heirs, dependents, executors,
parents, spouses, if any, and representatives of any kind, do not and will not
owe any amounts or sums of any kind or type in connection with the Dispute and
this Settlement Agreement other than the Settlement Payment, including, without
limitation, taxes, attorneys’ fees, costs, expenses, and/or damages relating to
any claims that were or could have been asserted under or in connection with the
Dispute.

 

15.                               General Release of Claims and Covenant Not to
Sue.

 

(A)                               Plaintiffs’ Release of Defendants and
Intervenor.  Upon payment of the Settlement Payment set forth in Paragraph 2,
the Plaintiffs, on behalf of themselves and any of their past, present, and
future agents, attorneys, administrators, trustees, trusts, trustors, settlors,
accountants, insurers, reinsurers, underwriters, predecessors, successors,
assigns, heirs, dependents, executors, parents, spouses, if any, and
representatives of any kind RELEASE, ACQUIT, AND GENERALLY RELEASE each of the
Defendants, the Non-Party Releasees, and the Intervenor, and any of their past,
present, and future principals, officers, directors, managers, partners,
shareholders, stockholders, members, employees, parent companies, subsidiaries,
affiliates, associated companies, agents, contractors, consultants, attorneys,
trustees, trusts, trustors, settlors, investors, accountants, insurers,
reinsurers, underwriters, predecessors, successors, assigns, and representatives
of any kind from all claims, debts, damages, penalties, fines, charges, demands,
rights, grievances, liabilities, attorneys’ fees, suits, matters, issues and
causes of action of every nature and description whatsoever known or unknown,
whether or not concealed or hidden, including, but not limited to, any claims
that were or could have been asserted in connection with the Dispute, as well as
any and all such claims, debts, damages, penalties, fines, charges,

 

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EXECUTION VERSION

 

demands, rights, grievances, liabilities, attorneys’ fees, suits, matters,
issues and causes of action of every nature and description whatsoever that
could be asserted in the future by Plaintiffs against any of the Defendants, the
Non-Party Releasees or the Intervenor arising out of or relating to the Dispute,
existing or accruing as of the date of receipt of the Settlement Payment. 
However, this Settlement Agreement is not intended to cover and does not apply
to Plaintiff Joshua Keel’s rights, if any, to pursue available workers’
compensation benefits, if any, in the future.  Any rights Plaintiffs may have
after the Effective Date with respect to future workers’ compensation benefits
will be controlled and governed by the law of New Mexico.

 

(B)                               Plaintiff Keel’s General Employment Release. 
Upon payment of the Settlement Payment set forth in Paragraph 2, Plaintiff Keel,
on behalf of himself and any of his past, present, and future agents, attorneys,
trustees, trusts, trustors, settlors, accountants, insurers, reinsurers,
underwriters, predecessors, successors, assigns, heirs, dependents, executors,
parents, spouses, if any, and representatives of any kind RELEASES, ACQUITS, AND
GENERALLY RELEASES Helmerich & Payne International Drilling Co. and Helmerich &
Payne, Inc. and any of their past, present, and future principals, officers,
directors, managers, partners, shareholders, stockholders, members, employees,
parent companies, subsidiaries, affiliates, associated companies, agents,
contractors, consultants, attorneys, trustees, trusts, trustors, settlors,
investors, accountants, insurers, reinsurers, underwriters, predecessors,
successors, assigns, and representatives of any kind (collectively, the “H&P
Releasees”) from all claims, counterclaims, debts, damages, penalties, fines,
charges, demands, rights, grievances, liabilities, attorneys’ fees, suits,
matters, issues and causes of action of every nature and description whatsoever
(including causes of action seeking declaratory or injunctive relief), known or
unknown, whether or not concealed or hidden, including, but not limited to, any
claims related to Keel’s employment with the H&P Releasees and separation
therefrom.  Plaintiff Keel releases and waives any and all claims, including but
not limited to those under any applicable federal laws, including, but not
limited to, Title VII of the Civil Rights Act of 1964, as amended, the Civil
Rights Act of 1991, 42 U.S.C. § 1981 (“Title VII”), the Americans with
Disabilities Act, as amended (“ADA”), the Equal Pay Act, as amended (“EPA”), the
Worker Adjustment and Retraining Notification Act, the Employee Retirement
Income Security Act of 1974, as amended, the Family and Medical Leave Act, as
amended, the Fair Labor Standards Act, as amended (“FLSA”), the Sarbanes-Oxley
Act, or under any applicable state or local laws or ordinances or any other
legal restrictions on the H&P Releasees’ rights, including the Texas Commission
on Human Rights Act and the New Mexico Human Rights Act.  Notwithstanding the
foregoing release in this Paragraph 15(B), this release does not waive Plaintiff
Joshua Keel’s rights to enforce this Agreement.  However, this Settlement
Agreement is not intended to cover and does not apply to Plaintiff Joshua Keel’s
rights, if any, to pursue available workers’ compensation benefits, if any, in
the future.  Any rights Plaintiffs may have after the Effective Date with
respect to future workers’ compensation benefits will be controlled and governed
by the law of New Mexico.

 

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(C)                               Defendants’ and Intervenor’s Release of Each
Other.  Upon entry of the court’s order dismissing the Declaratory Action with
prejudice as provided in Paragraph 8, each of the Defendants and the Intervenor,
on behalf of themselves and their insurers, reinsurers, and underwriters
RELEASE, ACQUIT, AND GENERALLY RELEASE each of the other Defendants and the
Intervenor and any of their respective past, present, and future principals,
officers, directors, managers, partners, shareholders, stockholders, members,
employees, parent companies, subsidiaries, affiliates, associated companies,
agents, contractors, consultants, attorneys, trustees, trusts, trustors,
settlors, investors, accountants, insurers, reinsurers, underwriters,
predecessors, successors, assigns, and representatives of any kind from all
claims, debts, damages, penalties, fines, charges, demands, rights, grievances,
liabilities, attorneys’ fees, suits, matters, issues and causes of action of
every nature and description whatsoever known or unknown, whether or not
concealed or hidden, including, but not limited to, any claims that were or
could have been asserted in connection with the Dispute, and all subrogation
claims and actions of any kind whatsoever that were or could have been filed by,
through or on behalf of H&P’s insurers and underwriters against the non-H&P
Defendants, subject to the terms provided herein, including but not limited to
Paragraph 13.

 

(D)                               The claims released by the Plaintiffs,
Defendants, and Intervenor are collectively the “Released Claims.”

 

(E)                                To the fullest extent permitted by law, the
Parties covenant not to (i) assert any Released Claims and any related claims,
including related future accrued claims, in any forum against any of the Parties
and any of their past, present, and future principals, officers, directors,
managers, partners, shareholders, stockholders, members, employees, parent
companies, subsidiaries, affiliates, associated companies, agents, contractors,
consultants, attorneys, trustees, trusts, trustors, settlors, investors,
accountants, insurers, reinsurers, underwriters, predecessors, successors,
assigns, heirs, dependents, executors, parents, spouses, if any, and
representatives of any kind, and (ii) encourage or assist anyone to assert any
Released Claims or related claims, including related future accrued claims,
against any of the Parties and any of their past, present, and future
principals, officers, directors, managers, partners, shareholders, stockholders,
members, employees, parent companies, subsidiaries, affiliates, associated
companies, agents, contractors, consultants, attorneys, trustees, trusts,
trustors, settlors, investors, accountants, insurers, reinsurers, underwriters,
predecessors, successors, assigns, heirs, dependents, executors, parents,
spouses, if any, and representatives of any kind.  However, this Settlement
Agreement is not intended to cover and does not apply to Plaintiff Joshua Keel’s
rights, if any, to pursue available workers’ compensation benefits, if any, in
the future.  Any rights Plaintiffs may have after the Effective Date with
respect to future workers’ compensation benefits will be controlled and governed
by the law of New Mexico.

 

16.                               Representations, Warranties, and INDEMNITY.
 By executing this Settlement Agreement and as a condition precedent to any
obligations or liabilities of the Parties, the Parties expressly acknowledge,
represent, and warrant that they (i) are not relying upon any statements,
understandings, representations, expectations, or agreements other than those
expressly set forth in this Settlement Agreement; (ii) have made their own
investigation of the facts and are relying solely upon their own knowledge and
the advice of their own legal counsel; (iii) knowingly waive any claim that this
Settlement Agreement was induced by any misrepresentation or nondisclosure and
any right to rescind or avoid this Settlement Agreement based upon presently
existing facts, known or unknown; (iv) are the lawful owner of the claims and
the potential claims released in this Settlement Agreement; (v) they have full
capacity and authority to settle,

 

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EXECUTION VERSION

 

compromise, and release their claims and potential claims and to enter into this
Settlement Agreement; (vi) no other person or entity has inherited, acquired, or
has been assigned, or will in the future inherit, acquire, or have any right to
assert, against any of the Parties any portion of the claims or potential claims
released in this Settlement Agreement; and (vii) they know of no other person or
entity that intends to assert a claim by, through, under, or on behalf of them,
and THE PARTIES EACH FURTHER AGREE TO INDEMNIFY AND/OR HOLD HARMLESS EACH OTHER
TO THE EXTENT A CLAIM OR CAUSE OF ACTION RELATED TO THE CLAIMS OR POTENTIAL
CLAIMS RELEASED IN THIS SETTLEMENT AGREEMENT IS BROUGHT BY, THROUGH, OR ON
BEHALF OF THAT PARTY AGAINST ANOTHER PARTY.  The Parties stipulate that each
Party is relying upon these representations and warranties in entering into this
Settlement Agreement.  These representations and warranties shall survive the
execution of this Settlement Agreement.

 

17.                               Notices.  Any notice, request, instruction, or
other document or communication required or permitted to be given under this
Settlement Agreement shall be in writing and shall be deemed given (i) upon
receipt if delivered in person, by a messenger, or courier service; or (ii)
three business days after being deposited in the U.S. mail, certified or
registered, return receipt requested, postage prepaid, addressed as follows:

 

If to Plaintiffs, delivered to:

 

Arnold & Itkin LLP

6009 Memorial Drive

Houston, TX 77007
Attention: Jason Itkin, Esq.

 

If to Devon Energy Corporation, Devon Energy Production Company, and/or Devon
International, Ltd., delivered and e-mailed to:

 

Hawash Meade Gaston Neese & Cicack LLP

2118 Smith Street

Houston, TX 77002

Attention:  Donald John Neese, Jr., Esq.

E-mail: jneese@hmgnc.com

 

If to Weatherford International LLC, delivered to:

 

Blank Rome LLP

717 Texas Avenue, Suite 1400

Houston, TX 77008

Attention:  Keith B. Letourneau, Esq.

 

If to Helmerich & Payne, Inc. and/or Helmerich & Payne International Drilling
Co., delivered to:

 

Helmerich & Payne, Inc.

1437 S. Boulder Ave., Suite 1400

Tulsa, OK 74119-3623

Attention:  Cara M. Hair, Esq.

 

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with a courtesy copy (which does not constitute notice) delivered to:

 

Sidley Austin LLP

2021 McKinney Avenue, Suite 2000

Dallas, TX 75201

Attention: Michelle Hartmann, Esq.

 

If to Wayne Duncan LLC, delivered to:

 

Bland & Partners, PCC

1717 St. James Place, Suite 360

Houston, TX 77056

Attention:  Susan Noe Wilson, Esq.

 

If to Battle Energy Services, LLC, delivered to:

 

Bland & Partners, PCC

1717 St. James Place, Suite 360

Houston, TX 77056

Attention:  Susan Noe Wilson, Esq.

 

If to Fuson Industrial Maintenance, LLC, delivered to:

 

Donato, Minx, Brown & Pool, P.C.

3200 Southwest Freeway, Suite 2300

Houston, TX 77027

Attention:  Robert D. Brown

 

If to Sierra Engineering, LLC, delivered to:

 

Ireson & Weizel, PLLC

9720 Cypresswood Drive, Suite 238

Houston, TX 77070

Attention:  Lansford O. Ireson

 

If to Man Welding Services, Inc., delivered to:

 

Royston Rayzor Vickery & Williams

1600 Smith Street, Suite 5000

Houston, TX 77002

Attention:  Terry Fitzgerald

 

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If to GSM Consulting, Inc. d/b/a GSM, Inc., delivered to:

 

Royston Rayzor Vickery & Williams

1600 Smith Street, Suite 5000

Houston, TX 77002

Attention:  Terry Fitzgerald

 

If to Jeff Lajoie, delivered to:

 

Royston Rayzor Vickery & Williams

1600 Smith Street, Suite 5000

Houston, TX 77002

Attention:  Terry Fitzgerald

 

If to New Hampshire Insurance Company, delivered to:

 

Adami, Shuffield, Scheihing & Burns

9311 San Pedro Avenue, Suite 900

San Antonio, TX 78216

Attention:  E. Wayne Shuffield

 

or to such other address or addresses as may be specified in writing from time
to time by any Party to the other Parties.

 

18.                               No Admission of Fault or Liability.  This
Settlement Agreement is made to terminate any and all controversies, real or
potential, asserted or unasserted, and claims for injuries or damages of any
nature whatsoever, real or potential, accrued or unaccrued, asserted or
unasserted, by the Parties relating in any way to the Dispute. Neither the
execution and delivery of this Settlement Agreement, nor compliance with its
terms, shall constitute an admission of any fault or liability on the part of
any of the Parties, or any of their respective agents, attorneys,
representatives, or employees.  None of the Parties to this Settlement Agreement
admits fault or liability of any sort and, in fact, all Parties expressly deny
fault and liability.  However, this Settlement Agreement is not intended to
cover and does not apply to Plaintiff Joshua Keel’s rights, if any, to pursue
available workers’ compensation benefits, if any, in the future.  Any rights
Plaintiffs may have after the Effective Date with respect to future workers’
compensation benefits will be controlled and governed by the law of New Mexico.

 

19.                               Consultation with Attorneys.  The Parties
understand and acknowledge that they have had the opportunity to retain
independent counsel to represent them in connection with their consideration of
this Settlement Agreement, and have done so.  The Parties represent and warrant
that each of them has undertaken its own investigation of the facts and is
relying solely upon its own knowledge and the advice of its counsel.  The
Parties further represent and warrant to each other that they have each
consulted with independent counsel and other advisors with respect to the
preparation, negotiation, and execution of this Settlement Agreement to the
extent they deemed such consultation necessary or appropriate, and have been
provided with a reasonable period of time to consider and execute this
Settlement Agreement.  The Parties, therefore, stipulate and agree that this
Settlement Agreement shall not be construed against any Party as the drafter
thereof.  All provisions of this Settlement Agreement have been negotiated by
the Parties at arms’ length, and no Party shall be deemed the scrivener of this
Settlement Agreement.

 

11

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EXECUTION VERSION

 

The Parties agree and direct that the rule of contract construction providing
that ambiguous contract terms should be interpreted against the drafting party
shall not apply nor be applied to this Settlement Agreement.  The
representations and warranties contained in this Paragraph shall survive the
execution of this Settlement Agreement.

 

20.                               Voluntary Agreement.  The Parties acknowledge
that they have read this Settlement Agreement and understand all of its terms
and that this Settlement Agreement is executed voluntarily, without duress, and
with full knowledge of its legal significance.  Each Party represents and
warrants that it has consulted with its legal advisors regarding the meaning and
advisability of this Settlement Agreement to the extent such Party has
determined such consultation to be necessary or appropriate.  Such
representations and warranties shall survive the execution of this Settlement
Agreement.

 

21.                               GOVERNING LAW.  THIS SETTLEMENT AGREEMENT
SHALL BE EXCLUSIVELY GOVERNED BY AND CONSTRUED ACCORDING TO THE LAWS OF THE
STATE OF TEXAS, EXCEPT THAT ANY PROVISIONS OF TEXAS LAW SUGGESTING OR REQUIRING
THE APPLICATION OF ANOTHER STATE’S LAW SHALL BE DISREGARDED.

 

22.                               Disputes Regarding This Agreement.  Any and
all disputes relating to or arising from this Settlement Agreement shall be
settled:  (i) first, by an attempt at mediation by the parties in Houston,
Texas, with the Parties to split the costs of such mediation; and (ii) second,
by a court of competent jurisdiction in Houston, Texas having venue over the
subject matter.  The Parties specifically consent to jurisdiction of the state
and federal courts sitting in Houston, Texas solely related to any disputes
regarding this Settlement Agreement.

 

23.                               Confidentiality.  The Parties each acknowledge
and agree that they will keep the negotiations leading to the Settlement
Agreement, as well as the terms and amount of the Settlement Agreement STRICTLY
AND COMPLETELY CONFIDENTIAL, and that they will not communicate or otherwise
disclose to anyone, the terms, amounts, copies, or fact of the Settlement
Agreement, except to state that the matter has been settled and as may be
required by law, including but not limited to the disclosure requirements of a
public company; provided, however, that the Parties may make such disclosures to
its accountants, bookkeepers, financial consultants, lawyers, tax advisors,
investors, insurers, regulators, and employees as necessary for the purpose of
operating its business, preparing and maintaining their books and records,
preparing income tax returns, or obtaining tax, financial, or legal advice. 
Each Party agrees that this paragraph is a material inducement to each other
Party entering into the Settlement Agreement.  Each Party agrees that each other
Party would be irreparably harmed by a breach of this paragraph and may seek an
ex parte temporary restraining order or other injunctive relief to enforce this
paragraph without posting a bond.  The Parties agree that the sum of ONE
THOUSAND DOLLARS AND ZERO CENTS ($1,000) out of the monies paid to Plaintiffs
constitutes consideration in support of the obligations set forth in this
Confidentiality Clause.

 

24.                               Public Statement.  Each of the Parties shall
make no public statement, including any posting on any social media outlet,
including those that may be personal or private, relating to the Dispute or the
Settlement Agreement.  Inquiries from the public will be responded to without
comment, other than to say that the matter has been settled.

 

12

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EXECUTION VERSION

 

Each Party agrees that this paragraph is a material inducement to each other
Party entering into the Settlement Agreement.  Each Party agrees that each other
Party would be irreparably harmed by a breach of this paragraph and may seek an
ex parte temporary restraining order or other injunctive relief to enforce this
paragraph without posting a bond.

 

25.                               Entire Agreement and Integration Clause.  This
Settlement Agreement integrates the whole of all agreements and understandings
of any sort or character between the Parties concerning the subject matter of
the Dispute and the Settlement Agreement (including all claims released herein),
and supersedes all prior negotiations, discussions, or agreements of any sort
whatsoever, whether oral or written, to the extent that such negotiations,
discussions, or agreements relate to (i) the Dispute or (ii) any claims that a
Party against whom this Settlement Agreement is sought to be enforced has
otherwise released in this Settlement Agreement.  NO REPRESENTATIONS,
AGREEMENTS, UNDERSTANDINGS, OR INDUCEMENTS (WHETHER WRITTEN, UNWRITTEN, VERBAL
OR OTHERWISE) SHALL AFFECT THE CONSTRUCTION OR ENFORCEMENT OF THIS SETTLEMENT
AGREEMENT, EXCEPT AS SET FORTH EXPRESSLY AND SPECIFICALLY IN THIS SETTLEMENT
AGREEMENT, IT BEING STIPULATED THAT, WITH RESPECT TO THE SUBJECT MATTER OF THIS
SETTLEMENT AGREEMENT (INCLUDING ALL CLAIMS RELEASED HEREIN), THE RIGHTS OF THE
PARTIES HERETO AGAINST ANY OPPOSING PARTY HERETO SHALL BE GOVERNED EXCLUSIVELY
BY THIS SETTLEMENT AGREEMENT.

 

26.                               Severability.  If any provision hereof is
invalid or unenforceable, then, to the fullest extent permitted by law, the
other provisions hereof shall remain in full force and effect and there shall be
deemed substituted for the provision at issue a valid, legal, and enforceable
provision as similar as possible to the provision at issue in order to carry out
the intentions of the Parties hereto as nearly as may be possible.

 

27.                               Amendments in Writing; No Waiver.  This
Settlement Agreement may only be amended or modified by a written instrument
that has been executed by the Parties.  The failure by any of the Parties to
enforce at any time, or for any period of time, any one or more of the terms or
conditions of this Settlement Agreement, or a course of dealing between the
Parties, shall not be a waiver of such terms or conditions or of such Party’s
right thereafter to enforce each and every term and condition of this Settlement
Agreement.

 

28.                               Construction.  Words in this Settlement
Agreement of the male, female, or neutral gender shall be construed to include
any other gender where appropriate.  Words used in this Settlement Agreement
that are either singular or plural shall be construed to include the other where
appropriate.

 

29.                               Headings.  The headings in this Settlement
Agreement are for convenience only and shall not limit, expand, affect, or alter
the meaning of any text.

 

30.                               Multiple Counterparts.  This Settlement
Agreement may be signed in multiple counterparts and, when each Party has signed
a counterpart hereof, each such counterpart shall be a binding and enforceable
agreement as an original.

 

13

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EXECUTION VERSION

 

31.                               Facsimile Signatures.  This Settlement
Agreement may be executed by facsimile or electronically transmitted signatures
(including by .pdf), and such facsimile or electronically transmitted signatures
will be deemed to be as valid as an original signature whether or not confirmed
by delivering the original signatures in person, by courier or by mail, although
it is the Parties’ intentions to deliver original signatures after delivery of
facsimile or electronically transmitted signatures.

 

THE UNDERSIGNED HAVE CAREFULLY READ THE FOREGOING CONFIDENTIAL SETTLEMENT
AGREEMENT, KNOW THE CONTENTS THEREOF, FULLY UNDERSTAND IT, AND SIGN THE SAME AS
ITS OWN FREE ACT.

 

[REMAINDER OF PAGE INTENTIONALLY BLANK]

 

14

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EXECUTION VERSION

 

AGREED, ACKNOWLEDGED, AND APPROVED:

 

 

PLAINTIFF:

 

DEFENDANT:

 

 

 

 

 

 

/s/ Joshua Keel

 

/s/ Cara M. Hair

Individually and as next friend of the minor children E.K. and V.K

 

DEFENDANT HELMERICH & PAYNE, INC.

 

 

 

 

 

 

/s/ [not legible]

 

/s/ Cara M. Hair

ATTORNEY FOR PLAINTIFF

 

DEFENDANT HELMERICH & PAYNE INTERNATIONAL DRILLING CO

 

 

 

/s/ Tina Kay

 

/s/ Tony D. Vaughn

Tina Kay

 

DEFENDANT DEVON ENERGY CORPORATION

 

 

 

 

 

 

 

 

/s/ Tony D. Vaughn

 

 

DEFENDANT DEVON ENERGY PRODUCTION COMPANY, LP

 

 

 

 

 

 

 

 

/s/ Tony D. Vaughn

 

 

DEFENDANT DEVON INTERNATIONAL, LTD.

 

 

 

 

 

 

 

 

/s/ Wayne Duncan

 

 

DEFENDANT WAYNE DUNCAN LLC

 

 

 

 

 

 

 

 

/s/ [not legible]

 

 

DEFENDANT WEATHERFORD INTERNATIONAL LLC

 

 

 

 

 

 

 

 

/s/ [not legible]

 

 

DEFENDANT BATTLE ENERGY SERVICES, LLC

 

15

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EXECUTION VERSION

 

 

 

/s/ [not legible]

 

 

DEFENDANT FUSON INDUSTRIAL MAINTENANCE, LLC

 

 

 

 

 

 

 

 

/s/ [not legible]

 

 

DEFENDANT SIERRA ENGINEERING, LLC

 

 

 

 

 

/s/ [not legible]

 

 

DEFENDANT MAN WELDING SERVICES, INC.

 

 

 

 

 

 

 

 

/s/ [not legible]

 

 

DEFENDANT GSM CONSULTING INC. D/B/A GSM, INC.

 

 

 

 

 

 

 

 

/s/ Jeff Lajoie

 

 

DEFENDANT JEFF LAJOIE

 

 

 

 

 

 

 

 

/s/ E. Wayne Sheffield

 

 

INTERVENOR NEW HAMPSHIRE INSURANCE COMPANY

 

 

 

APPROVED AS TO FORM:

 

 

 

 

 

/s/ Donna Roth

 

 

Donna Roth

 

 

GUARDIAN AD LITEM for Plaintiff Joshua Keel

 

 

 

 

 

 

 

 

/s/ Ana Hernandez

 

 

Ana Hernandez

 

 

GUARDIAN AD LITEM for Plaintiff Erin Keel

 

 

 

 

 

/s/ Ana Hernandez

 

 

Ana Hernandez

 

 

GUARDIAN AD LITEM for Plaintiff Veda Keel

 

 

 

16

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EXHIBIT A TO CONFIDENTIAL SETTLEMENT

AGREEMENT AND GENERAL RELEASE OF CLAIMS

 

This Exhibit A sets forth the distribution of the Settlement Payment stated in
paragraph 2 of the Settlement Agreement.  Helmerich & Payne Inc. and/or its
insurers and/or its underwriters (collectively, the “Payor”) agree to pay or
cause to be paid the following:

 

1.0                               Cash at Settlement:

 

Cash in the amount of $43,959,350.00 payable to Plaintiff Joshua Keel, as
plaintiff and next friend of E.K. and V.K., and Arnold & Itkin LLP as co-payees,
which includes an Initial Deposit in the amount of $155,502.00 for the MSA
Account for Plaintiff Joshua Keel.

 

2.0                               Periodic Payments:

 

A. Payor shall pay or cause to be paid the periodic payments outlined below. The
periodic payments will be funded with a present value of Sixteen Million Forty
Thousand Six Hundred Fifty Dollars and No/100 ($16,040,650.00) payable to BHG
Structured Settlements, Inc. to fund the future periodic payments respectively
described below.

 

Periodic Payments Payable to Joshua Keel Special Care Trust (“Payee”)

 

$50,188.00 payable monthly for the life of Joshua Keel with forty (40) years
guaranteed.  Payments commence January 15, 2017 with the last guaranteed payment
payable December 15, 2056.

 

$43,573.68 payable annually for the life of Joshua Keel with forty (40) years
guaranteed.  Payments commence January 1, 2018 with the last guaranteed payment
payable January 1, 2057.

 

Following Joshua Keel’s death, 100% of the remaining and unpaid certain payments
listed below as Commutable Payments will be commuted in exchange for a lump sum
equal to 95% of the present value of the unpaid Commutable Payments, as
calculated by the Annuity Issuer. The present value will be computed using a
discount rate equal to the annual effective yield on the date of death of Joshua
Keel of the highest yielding U.S. treasury strip available as reported in the
Wall Street Journal (or an equivalent source of such information), plus 200
basis points (2 percentage points). If the date of Joshua Keel’s death is not a
business day, the yield on the next business day will be used. The commutation
payment will be determined within 30 days after the Annuity Issuer is notified
in writing of the death of Joshua Keel.

 

The commutation payment will be paid to the person, persons, or entity named as
the Contingent Payee under the Annuity Contract.

 

The payee designation for a specific payment may be irrevocable, and nothing
herein shall imply that any Commutable Payment is eligible for transfer to any
other person. However, if Joshua Keel has transferred any amount of a specific
payment to any other person pursuant to an order of a court under applicable
state law, the amount so transferred will not be considered to be a Commutable
Payment.

 

1

--------------------------------------------------------------------------------

 

The amount so transferred will first be deducted from that portion of the
specific payment which is not listed below as a Commutable Payment.  If the
amount transferred cannot be fully satisfied exclusive of the that portion
listed below as a Commutable Payment, any remaining amount necessary to satisfy
said transfer shall be deemed to have been removed from the Commutable Payments
hereunder.

 

COMMUTABLE PAYMENTS:

 

$50,188.00 payable monthly for forty (40) years guaranteed.  Payments commence
January 15, 2017 with the last guaranteed payment payable December 15, 2056.

 

$43,573.68 payable annually for forty (40) years guaranteed.  Payments commence
January 1, 2018 with the last guaranteed payment payable January 1, 2057.

 

B. Payor shall pay or cause to be paid the periodic payments outlined below. The
periodic payments will be funded with a present value of Ten Million Dollars and
No/100 ($10,000,000.00) payable to MetLife Tower Resources Group, Inc. to fund
the future periodic payments described below.

 

Periodic Payments Payable to Joshua Keel Special Care Trust (“Payee”)

 

$32,653.40 payable monthly for the life of Joshua Keel with forty (40) years
guaranteed.  Payments commence January 15, 2017 with the last guaranteed payment
payable December 15, 2056.

 

If Joshua Keel dies and there remain any unpaid payments due under this
certificate, 100% of such payments will be commuted and paid to the payee named
by the Owner in a single sum.

 

MetLife will pay a commuted value equal to 95 percent of the present value of
the remaining guaranteed benefits under this certificate which would provide
such commuted payments. MetLife will compute this value as of the date of death
of Joshua Keel. MetLife will use its then current annuity rates for the same or
similar certificates in effect on such date.  If such annuity rates are not
available at the time of MetLife’s determination of the commuted value, then the
commuted payment will be calculated on the basis of the interest rate
assumptions used to price any annuity upon which MetLife determines are
competitive rates over the appropriate time frame.

 

C. Payor shall pay or cause to be paid the periodic payments outlined below. The
periodic payments will be funded with a present value of One Million Dollars and
No/100 ($1,000,000.00) payable to BHG Structured Settlements, Inc. to fund the
future periodic payments described below.

 

(i) Periodic Payments Payable to Erin Keel Settlement Preservation Trust
(“Payee”)

 

$25,000.00 payable semi-annually for five (5) years guaranteed (10 payments). 
Payments commence November 6, 2025 with the last guaranteed payment payable May
6, 2030.

 

2

--------------------------------------------------------------------------------

 

$1,000.00 payable monthly for five (5) years guaranteed.  Payments commence
November 6, 2025 with the last guaranteed payment payable October 6, 2030.

 

$2,500.00 payable monthly for seven (7) years guaranteed.  Payments commence
November 6, 2030 with the last guaranteed payment payable October 6, 2037.

 

$  50,000.00 guaranteed lump sum payable November 6, 2030.

$100,000.00 guaranteed lump sum payable November 6, 2032.

$150,000.00 guaranteed lump sum payable November 6, 2034.

 

(ii) Periodic Payments Payable to Erin Keel (“Payee”)

 

$2,500.00 payable monthly for five (5) years guaranteed.  Payments commence
November 6, 2037 with the last guaranteed payment payable October 6, 2042.

 

$200,000.00 guaranteed lump sum payable November 6, 2037.

$671,000.00 guaranteed lump sum payable November 6, 2042.

 

D. Payor shall pay or cause to be paid the periodic payments outlined below. The
periodic payments will be funded with a present value of One Million Dollars and
No/100 ($1,000,000.00) payable to BHG Structured Settlements, Inc. to fund the
future periodic payments described below.

 

(i) Periodic Payments Payable to Veda Keel Settlement Preservation Trust
(“Payee”)

 

$25,000.00 payable semi-annually for five (5) years guaranteed (10 payments). 
Payments commence January 20, 2028 with the last guaranteed payment payable July
20, 2032.

 

$1,000.00 payable monthly for five (5) years guaranteed.  Payments commence
January 20, 2028 with the last guaranteed payment payable December 20, 2032.

 

$2,500.00 payable monthly for seven (7) years guaranteed.  Payments commence
January 20, 2033 with the last guaranteed payment payable December 20, 2039.

 

$  50,000.00 guaranteed lump sum payable January 20, 2033.

$100,000.00 guaranteed lump sum payable January 20, 2035.

$150,000.00 guaranteed lump sum payable January 20, 2037.

 

(ii) Periodic Payments Payable to Veda Keel (“Payee”)

 

$2,500.00 payable monthly for five (5) years guaranteed.  Payments commence
January 20, 2040 with the last guaranteed payment payable December 20, 2044.

 

$300,000.00 guaranteed lump sum payable January 20, 2040.

$778,000.00 guaranteed lump sum payable January 20, 2045.

 

3

--------------------------------------------------------------------------------

 

All sums set forth herein constitute damages on account of personal physical
injuries or sickness, within the meaning of §104(a)(2) of the Internal Revenue
Code of 1986, as amended.

 

3.0                               Rights to Payments:

 

Plaintiffs acknowledge and agree that neither the Periodic Payments nor any
rights thereto or interest therein (collectively, “Payment Rights”) can be:

 

(a)                                 accelerated, deferred, increased or
decreased by Plaintiffs or any Payee;

 

(b)                                 sold, mortgaged, assigned, pledged,
hypothecated or otherwise transferred or encumbered, either directly or
indirectly, by Plaintiffs or any Payee unless such sale, assignment, pledge,
hypothecation or other transfer or encumbrance (any such transaction being
hereinafter referred to as a “Transfer”) has been approved in advance in a
“qualified order” as outlined in Section 5891(b)(2) of the Internal Revenue Code
of 1986, as amended (a “Qualified Order”), and approved by a court of competent
jurisdiction and otherwise complies with applicable state law, including without
limitation any and all applicable state structured settlement protection
statutes.

 

Plaintiffs or any Payee shall not have the power to affect a Transfer of Payment
Rights except as provided in subparagraph (b) above, and any other purported
Transfer of Payment Rights shall be wholly void.

 

4.0                               Beneficiary:

 

Any payments to be made after the death of Joshua Keel pursuant to the terms of
this Exhibit A to the Confidential Settlement Agreement and General Release of
Claims in paragraphs 2.0 A. and 2.0 B. shall be made to the Joshua Keel Special
Care Trust.  If the entity or person designated is not in existence/living at
the time of Joshua Keel’s death, such payments shall be made to the Estate of
Joshua Keel.  No such designation, nor any revocation thereof, shall be
effective unless it is in writing and delivered to Payor’s Assignee.  The
designation must be in a form acceptable to Payor’s Assignee before such
payments are made.

 

Any payments to be made after the death of Erin Keel pursuant to the terms of
this Exhibit A to the Confidential Settlement Agreement and General Release of
Claims in paragraph 2.0 C. shall be made to the Estate of Erin Keel, unless
otherwise Court ordered, until the age of majority.  Upon reaching the age of
majority, Erin Keel may designate any such person or entity as beneficiary in
writing to the Payor’s Assignee.  If no such person or entity is so designated
by Erin Keel, or if the person designated is not living at the time of Erin
Keel’s death, such payments shall be made to the Estate of Erin Keel.  No such
designation, nor any revocation thereof, shall be effective unless it is in
writing and delivered to the Payor’s Assignee.  The designation must be in a
form acceptable to the Payor’s Assignee before such payments are made.

 

4

--------------------------------------------------------------------------------

 

Any payments to be made after the death of Veda Keel pursuant to the terms of
this Exhibit A to the Confidential Settlement Agreement and General Release of
Claims in paragraph 2.0 D. shall be made to the Estate of Veda Keel, unless
otherwise Court ordered, until the age of majority.  Upon reaching the age of
majority, Veda Keel may designate any such person or entity as beneficiary in
writing to the Payor’s Assignee.  If no such person or entity is so designated
by Veda Keel, or if the person designated is not living at the time of Veda
Keel’s death, such payments shall be made to the Estate of Veda Keel.  No such
designation, nor any revocation thereof, shall be effective unless it is in
writing and delivered to the Payor’s Assignee.  The designation must be in a
form acceptable to the Payor’s Assignee before such payments are made.

 

5.0                               Consent to Qualified Assignment:

 

Plaintiffs acknowledge and agree that Payor shall make a “qualified assignment”,
within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as
amended, of Payor’s liability to make the periodic payments as set forth in
paragraphs 2.0 A., 2.0 C. and 2.0 D. to BHG Structured Settlements, Inc.
(“Assignee”).  The Assignee’s obligation for the payment of the periodic
payments shall be no greater than that of Payor (whether by judgment or
agreement) immediately preceding the assignment of their periodic payments
obligation.

 

Plaintiffs acknowledge and agree that Payor shall make a “qualified assignment”,
within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as
amended, of Payor’s liability to make the periodic payments as set forth in
paragraph 2.0 B. to MetLife Tower Resources Group, Inc. (“Assignee”).  The
Assignee’s obligation for the payment of the periodic payments shall be no
greater than that of Payor (whether by judgment or agreement) immediately
preceding the assignment of their periodic payments obligation.

 

Such assignments shall be accepted by Plaintiffs without right of rejection and
shall completely release and discharge Payor from the Periodic Payments
obligation assigned to the respective Assignee.  Plaintiffs recognize that the
respective Assignee shall be the sole obligor with respect to the Periodic
Payments obligation that pertains to the liability of Payor shall thereupon
become final, irrevocable and absolute.

 

6.0                               Right to Purchase an Annuity:

 

BHG Structured Settlements, Inc., Assignee, shall fund the liability to make the
Periodic Payments outlined in paragraphs 2.0 A., 2.0 C. and 2.0 D. through the
purchase of annuity policies from Berkshire Hathaway Life Insurance Company of
Nebraska (“Annuity Issuer”).  BHG Structured Settlements, Inc. shall be the sole
owner of the annuity policies and shall have all rights of ownership.  BHG
Structured Settlements, Inc. may have Berkshire Hathaway Life Insurance Company
of Nebraska mail payments directly to the Payee(s).  Said Payee(s) shall be
responsible for maintaining a current mailing address with BHG Structured
Settlements, Inc.

 

5

--------------------------------------------------------------------------------

 

MetLife Tower Resources Group, Inc., Assignee, shall fund the liability to make
the Periodic Payments outlined in paragraph 2.0 B. through the purchase of an
annuity policy from Metropolitan Life Insurance Company (“Annuity Issuer”). 
MetLife Tower Resources Group, Inc. shall be the sole owner of the annuity
policy and shall have all rights of ownership.  MetLife Tower Resources Group,
Inc. may have Metropolitan Life Insurance Company mail payments directly to the
Payee(s).  Said Payee(s) shall be responsible for maintaining a current mailing
address with MetLife Tower Resources Group, Inc.

 

7.0                               Discharge of Obligation:

 

The obligation of the respective Assignee to make each Periodic Payment shall be
fully discharged upon the mailing of a valid check or electronic funds transfer
in the amount of such payment on or before the due date to the last address on
record for the Payee(s) with the respective Annuity Issuer. If a Payee notifies
an Assignee that any check or electronic funds transfer was not received, the
respective Assignee shall direct the respective Annuity Issuer to initiate a
stop payment action and, upon confirmation that such check was not previously
negotiated or electronic funds transfer deposited, shall have the respective
Annuity Issuer process a replacement payment.

 

IN ENTERING INTO THIS AGREEMENT, PLAINTIFFS REPRESENT THAT THEY HAVE COMPLETELY
READ ALL OF ITS TERMS AND THAT SUCH TERMS ARE FULLY UNDERSTOOD AND VOLUNTARILY
ACCEPTED BY PLAINTIFFS.  PLAINTIFFS HAVE BEEN REPRESENTED BY COUNSEL OF THEIR
OWN CHOICE.

 

PLAINTIFF:

 

 

 

 

 

 

 

Joshua Keel, Individually and as next friend of the minor children E.K. and V.K

 

 

 

 

 

 

 

ATTORNEY FOR PLAINTIFF

 

 

 

 

 

 

 

Tina Kay

 

 

6

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Exhibit B

 

[g181163ku07i001.jpg]

 

Name: Joshua Keel

Date of Injury: 7/11/2014

Date of Report: 9/20/2016

 

Thank you for your referral. The summary of costs associated with the Medicare
Set-Aside is noted below for your review. Please see the attached report for
more detailed explanation.

 

Summary Outline

 

MSA Allocation:

 

Injury-Related Diagnosis:

Major neurocognitive disorder due to traumatic brain injury

Traumatic amputation of the left upper extremity at the shoulder

Chronic pain

Avulsion of the brachial plexus nerve roots

Avulsion of cervical roots

Neck pain

Mid back pain

Left facial paralysis

Exposure keratopathy

Nasal obstruction

Bilateral inferior turbinate hypertrophy

Mixed hearing loss, unilateral, on the left

Phrenic nerve injury

Hypoxia

Anxiety

Major depressive disorder, single episode, moderate

 

Total proposed Future Medical treatment (Part A & B):

 

$

1,435,191.48

 

Total proposed Future Prescription Drug treatment (Part D):

 

$

550,404.82

 

Total proposed MSA Amount:

 

$

1,985,596.30

 

 

[g181163ku07i002.jpg]

 

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Annuity Funding:

 

Rated Age: 37

 

Life Expectancy: 43

 

If a structured settlement is utilized to fund the MSA Account, the annuity
should provide:

 

Initial Deposit: $155,502.00                                Annual Payments:
$43,573.68

 

If an annuity will be utilized to fund the MSA Account, a seed amount (to
include two years annual cost) to be followed by annual deposit over the
remainder of the life expectancy as noted above is recommended.

 

--------------------------------------------------------------------------------

 

Name: Joshua Keel

 

Date of Accident: 7/11/2014

Date of Birth: 2/7/1986

 

State of Jurisdiction: NM

Medicare Recipient: Not a Medicare

 

Prepared By: Melissa Grimes, RN,

Beneficiary

 

CLCP, MSCC

Effective Date of Medicare:

 

Date of Report: 9/20/2016

Part A: N/A

 

Date Report Sent: 9/20/2016

Part B: N/A

 

 

Part D: N/A

 

 

 

LIABILITY

MEDICARE SET-ASIDE REPORT

 

1.                           INTRODUCTION:

 

This Liability Medicare Set-Aside Allocation was developed from a review of the
medical records provided and research related to Joshua Keel’s injury claim,
diagnosis and medical treatment. This Medicare Set-Aside Allocation will address
current and future medical/rehabilitation needs typically covered by Medicare
for Joshua Keel’s life expectancy. This report is based on the following body
parts/conditions:

 

·              Head

·              Face

·              Eye

·              Hearing

·              Left upper extremity amputation

·              Cervical spine

·              Thoracic spine

·              Chest/Pulmonary

·              Psychological

 

2.                          CHRONOLOGICAL MEDICAL SUMMARY:

 

A heavy piece of machinery fell and struck Mr. Keel on his left side causing a
traumatic brain injury, crush injury to his left chest, traumatic amputation of
his left upper extremity, and a brachial plexus injury. Additional conditions
noted included a skull fracture, facial fractures, ethmoid sinus fractures,
incomplete eye closure, left facial paralysis, hearing loss on the left, left
transverse process fractures of C3-6, left transverse process fracture of T2,
multiple rib fractures, and a phrenic nerve injury/paralyzed left hemidiaphragm.

 

--------------------------------------------------------------------------------

 

In 8/2014, Mr. Keel required in-patient treatment of his intractable pain. He
was treated with Intravenous (IV) medications and then a Patient-Controlled
Analgesia (PCA) pump. He was subsequently transferred to another facility for
further rehabilitation. Oversight was provided primarily by a physiatrist, but
Mr. Keel was also monitored by a neurosurgeon, neurootologist, otolaryngologist,
pulmonologist, and psychologist. He temporarily wore a hard cervical collar and
utilized a TENS unit. Mr. Keel was also maintained on oxygen via nasal cannula.
His head injury was described as mild and while no seizure activity was
reported, he was prescribed medication for seizure prophylaxis. No specific
treatment was recommended relative to Mr. Keel’s left sided hearing loss.
Mr. Keel participated in physical, pool, speech, and massage therapy. A working
prototype prothesis was provided for the left upper extremity in 11/2014. After
Mr. Keel reportedly failed various brachial plexus and cervical stellate
ganglion blocks, a spinal cord stimulator was suggested. Repeat diagnostic
studies showed healing of the fracture sites.

 

Mr. Keel remained under the care of a physiatrist, neurosurgeon,
otolaryngologist, and psychologist into 2015. He participated in further
physical, pool, occupational, and massage therapy. Speech therapy noted
improvement in the areas of cognition. Continual oxygen was needed due to severe
chronic hypoxia. A left arm diagnostic prosthesis was provided and ultimately
replaced with a final myoelectric prosthesis later in the year. For management
of nasal obstruction due to septal deviation and bilateral inferior turbinate
hypertrophy, both the treating otolaryngologist and a consulting oral surgeon
discussed surgery consisting of a septoplasty and inferior turbinate reduction.

 

On 4/13/2015, Mr. Keel underwent implantation of a high cervical spinal cord
stimulator performed by the treating neurosurgeon. Further use of a TENS unit
was not indicated following placement of the implanted spinal cord stimulator.
Mr. Keel eventually relocated to his home state and resided with his brother.
His ongoing care was assumed by a new physiatrist/pain management specialist.
Mr. Keel complained of cervical and thoracic spine pain as well as anxiety.

 

Neuropsychological testing was conducted in 8/2015 resulting in diagnoses of
major neurocognitive disorder due to traumatic brain injury, major depressive
disorder, and anxiety disorder. Following the neuropsychological testing, it was
noted that Mr. Keel would benefit from a psychiatric evaluation and
psychotherapy. The same neuropsychiatrist conducted an independent brain injury
functional evaluation as part of the Project Re-Entry program. He recommended a
comprehensive outpatient cognitive rehabilitation program along with individual
psychotherapy.

 

--------------------------------------------------------------------------------

 

In 9/2015, Mr. Keel was also evaluated by a plastic surgeon. There were again
recommendations for a nasal septal resection and reduction of the turbinates.
There was also a recommendation for a lateral tarsorrhaphy of the lateral
canthus of the left eye. This procedure would allow for closure of the paralyzed
eye lid and prevent drying of the eye. The plastic surgeon noted the possibility
that Mr. Keel’s left side of the face could start to droop and sag; therefore,
within 5-10 years, he would benefit from a fascia lata sling support suspension.
He indicated this procedure would require follow up surgeries every 10 years for
retightening. Mr. Keel was reportedly concerned about the muscle mass lateral to
his left breast, which was the remains of the forearm muscle attachment of the
pectoralis major and minor muscles to the humerus. Consequently, the plastic
surgeon discussed that the muscle could be lifted up, debulked, and suspended to
the remains of the shoulder or clavicle with tendon transfer to fill out the
hollow areas of the shoulder. However, it was noted that this would be a lot of
surgery and the resultant pain might not be tolerated. It was suggested that any
potential surgery would need to be supported by pain management before it was
performed.

 

Mr. Keel underwent urological work up in early 2016, but no obstruction or
significant pathology was noted. During his regular neurosurgical follow up
visit, Mr. Keel was noted to be doing well with his spinal cord stimulator,
which was providing meaningful pain relief. The stimulator underwent standard
reprograming. Mr. Keel was also seen for adjustment to the left external powered
prosthesis. Problems with myoelectric control as well as heaviness and
cumbersomeness resulted in Mr. Keel not wearing the device part of the time.
Further adjustments and changes were recommended to assist with better function
and wear. Mr. Keel remained on continuous oxygen due to diminished lung capacity
and left hemidiaphragm problems. There were short-term memory deficits reported,
but Mr. Keel continued to live independently with his brother. No ongoing
psychotherapy was noted. During a follow up with the plastic surgeon, a
turbinectomy to improve nasal breathing and a tarsorrhaphy of the left lateral
eye were again discussed. It was recommended that these surgeries not be
performed on an outpatient basis due to Mr. Keel’s breathing problems. The
plastic surgeon ultimately suggested these elective surgeries be put off for now
with further follow up in one year.

 

Mr. Keel also came under the care of an ophthalmologist during 2016 for
management of his dry, irritated eye. The diagnosis was exposure keratopathy on
the left. Treatment consisted of a PROSE device. Medication management according
to the medication history included Fentanyl patches, Lyrica, Methadone,
Oxycodone, Meloxicam, Zorvolex, Levetiracetam, and Sertraline. While Baclofen
was filled in 2015 and Gabapentin in 1/2016 only, neither medication was
continued.

 

--------------------------------------------------------------------------------

 

3.                               INJURY-RELATED DIAGNOSIS (with ICD Codes):

 

·                  Z87.820 Major neurocognitive disorder due to traumatic brain
injury

·                  S48.912A Traumatic amputation of the left upper extremity at
the shoulder

·                  G89.21 Chronic pain

·                  G54.0 Avulsion of the brachial plexus nerve roots

·                  S14.2XXA Avulsion of cervical roots

·                  M54.2 Neck pain

·                  M54.9 Mid back pain

·                  S04.52XS Left facial paralysis

·                  H16.219 Exposure keratopathy

·                  J34.89 Nasal obstruction

·                  J34.3 Bilateral inferior turbinate hypertrophy

·                  H90.72 Mixed hearing loss, unilateral, on the left

·                  J98.6 Phrenic nerve injury

·                  J96.91 Hypoxia

·                  F41.9 Anxiety

·                  F32.2 Major depressive disorder, single episode, moderate

 

4.                               ANTICIPATED MEDICARE COVERED SERVICES:

 

Future Medical Need of the type
normally covered by Medicare

 

CPT/ Code

 

Frequency & Duration of
Need

 

Physiatrist/Pain management visits

 

99213

 

4/year/LE

 

Neurosurgeon visits

 

99214

 

1/year/LE

 

Neurootology visits

 

99214

 

1/year/LE

 

Otolaryngologist visits

 

99214

 

1/year/LE

 

Plastic surgeon visits

 

99214

 

1/year/LE

 

Ophthalmologist visits

 

99214

 

1/year/LE

 

Pulmonologist visits

 

99213

 

4/year/LE

 

Psychiatric evaluation

 

99214

 

1/LE

 

Psychotherapy

 

90837

 

100/LE

 

Physical/Pool therapy

 

97110 x 3

 

48/LE

 

Occupational therapy

 

97110 x 3

 

48/LE

 

Speech therapy

 

97532 x 3

 

24/LE

 

Neuropsychological testing

 

96102 x 5

 

2/LE

 

Head CT scan without contrast

 

70450

 

6/LE

 

Temporal bone CT scan without contrast

 

70480

 

6/LE

 

Facial CT scan without contrast

 

70486

 

6/LE

 

Facial bone x-rays

 

70150

 

14/LE

 

Cone beam CT scan with and without contrast

 

70488

 

8/LE

 

Sinus x-rays

 

70220

 

14/LE

 

 

--------------------------------------------------------------------------------

 

ENOG testing

 

92516

 

6/LE

 

EEG

 

95953

 

4/LE

 

Cervical CT scan without contrast

 

72125

 

6/LE

 

Cervical x-rays

 

72050

 

14/LE

 

Thoracic CT scan without contrast

 

72128

 

6/LE

 

Thoracic x-rays

 

72074

 

14/LE

 

Chest CT scan without contrast

 

71250

 

6/LE

 

Chest x-rays

 

71020

 

14/LE

 

Pulmonary function tests

 

All Inclusive

 

1/year/LE

 

Electrodiagnostic testing of diaphragm

 

95866

 

6/LE

 

SNIFF test

 

76000

 

6/LE

 

CMP

 

80053

 

1/year/LE

 

CBC

 

85025

 

1/year/LE

 

Levetiracetam level

 

80177

 

1/year/LE

 

Venipuncture

 

36415

 

1/year/LE

 

Pneumococcal vaccine

 

All Inclusive

 

2/LE

 

Influenza vaccine

 

All Inclusive

 

1/year/LE

 

Portable oxygen system rental

 

E1392

 

12/year/27 years;

 

 

 

 

 

Medicare coverage for the O2 is only for a total of 3 years out of every 5 year
cycle

 

Stationary oxygen system rental

 

E1390

 

12/year/27 years;

 

 

 

 

 

Medicare coverage for the O2 is only for a total of 3 years out of every 5 year
cycle

 

Spinal cord stimulator revisions

 

All Inclusive

 

6/LE

 

Spinal cord stimulator

 

All Inclusive

 

2/year/LE

 

reprogramming

 

 

 

 

 

Septoplasty with reduction of the turbinates

 

All Inclusive

 

1/LE

 

Tarsorrhaphy, left eye

 

All Inclusive

 

1/LE

 

Prosthesis

 

All Inclusive

 

8/LE

 

Prosthesis repairs

 

All Inclusive

 

Yearly except for year of replacement

 

Stump liners

 

L5673

 

6/year/LE

 

Cosmetic cover

 

All Inclusive

 

1/year/LE

 

Protective skin

 

All Inclusive

 

1/year/LE

 

Battery

 

All Inclusive

 

22/LE

 

Left upper extremity stump x-ray

 

73030

 

22/LE

 

 

--------------------------------------------------------------------------------

 

Brachial plexus and cervical stellate ganglion blocks were not beneficial and
therefore, are not included in the future care. The fascia lata sling support
suspension and the procedure to lift up, debulk, and suspend the remains of the
left shoulder/clavicle region were only discussed as possible treatment options.
Neither surgery was addressed during the plastic surgeon’s reevaluation in 2016.
As these procedures are not actively recommended, they will not be included in
the MSA.

 

Lyrica is an anticonvulsant medication utilized off label for neuropathic spine
pain without evidence of spinal cord injury and therefore, it is not covered by
Medicare Part D. Additionally massage therapy is not covered by Medicare.

 

While an extensive cognitive rehabilitation program was discussed in 2015, this
program would not meet Medicare coverage guidelines more than 24 months out from
the traumatic brain injury. Thus, the program would not be covered by Medicare.
The PROSE device is not utilized for the conditions/diagnoses supporting
Medicare coverage.

 

5.                                 LIFE EXPECTANCY:

 

Joshua Keel’s median rated age of 37 years has been determined using statements
from The Settlement Alliance — Houston, TX. Per the National Vital Statistics
Report and Centers for Disease Control and Prevention 2011, Vol. 64, No. 11,
September 22, 2015, for total population; Joshua Keel’s adjusted life
expectancy, based upon rated age, is 43 years which will be utilized as a basis
for the calculations in this report.

 

While it is not possible to accurately predict all future medical and
technological advances or associated complications pertaining to Joshua Keel’s
injury of 7/11/2014, the Medicare Set-Aside Allocation grids are thought to
reflect what can be reasonably anticipated for Joshua Keel’s future medical care
based on the information provided. Medicare’s reimbursement guidelines were
considered to determine potential Medicare covered expenses. Present day costs
were utilized and no provision has been made for future inflation.

 

6.                                 MEDICARE ALLOCATION AMOUNT:

 

The total Liability Medicare Set-Aside recommended amount is $1,985,596.30
inclusive of both future medical and future prescription treatment. If an
annuity will be utilized to fund the Medicare Set-Aside account, the following
are our recommendations. A seed amount of $155,501.90 (to include two years
annual cost including septoplasty with turbinate reduction surgery and
replacement of the prosthesis) to be followed by annual deposits of $43,573.68
for the remainder of the life expectancy.

 

--------------------------------------------------------------------------------

 

References

 

·                  Cost projections are based on 80% Usual & Customary charges;
claimant lives in LA — Louisiana, zip code 71016

·                  Prices obtained from SmartAdvisor

·                  Surgical cost obtained from Healthcare Bluebook

·                  DME pricing obtained from Noridian Healthcare Solutions

·                  The average wholesale price (per Redbook pricing) was used
for drug pricing

·                  Truven Micromedex DrugDex®

·                  National Medical Policy: Cognitive Rehabilitation Post
Traumatic Brain Injury, Policy Number: NMP129

·                  Massage:
http://www.medicare.gov/coverage/massage-therapy.html

·                  Oxygen:
https://www.virtuox.net/Dyndocs/Documents/LCDforOxygen.pdf

·                  PROSE device:

https://www.dmepdac.com/resources/articles/2015/10_09_15.html

 

--------------------------------------------------------------------------------

 

MEDICAL ALLOCATION

 

Name: Joshua Keel

 

 

 

Life Expectancy:

 

 43

 

Date of Report: 9/20/2016

 

 

 

 

 

 

 

 

 

 

 

Future Medical Need of

 

 

 

 

 

 

 

 

 

 

 

Total

 

 

 

the type normally

 

 

 

Frequency & Duration of

 

Per Unit

 

# of units/

 

Annual

 

# of

 

Total Cost Over

 

covered by Medicare

 

CPT/ Code

 

Need

 

Cost

 

year

 

Cost

 

Years

 

Life Expectancy

 

Physiatrist/Pain management visits

 

99213

 

4/year/LE

 

$

140.21

 

4

 

$

560.84

 

43

 

$

24,116.12

 

Neurosurgeon visits

 

99214

 

1/year/LE

 

$

203.20

 

1

 

$

203.20

 

43

 

$

8,737.60

 

Neurootology visits

 

99214

 

1/year/LE

 

$

203.20

 

1

 

$

203.20

 

43

 

$

8,737.60

 

Otolaryngologist visits

 

99214

 

1/year/LE

 

$

203.20

 

1

 

$

203.20

 

43

 

$

8,737.60

 

Plastic surgeon visits

 

99214

 

1/year/LE

 

$

203.20

 

1

 

$

203.20

 

43

 

$

8,737.60

 

Ophthalmologist visits

 

99214

 

1/year/LE

 

$

203.20

 

1

 

$

203.20

 

43

 

$

8,737.60

 

Pulmonologist visits

 

99213

 

4/year/LE

 

$

140.21

 

4

 

$

560.84

 

43

 

$

24,116.12

 

Psychiatric evaluation

 

99214

 

1/LE

 

$

203.20

 

1

 

$

203.20

 

1

 

$

203.20

 

Psychotherapy

 

90837

 

100/LE

 

$

227.12

 

100

 

$

22,712.00

 

1

 

$

22,712.00

 

Physical/Pool therapy

 

97110 x 3

 

48/LE

 

$

183.45

 

48

 

$

8,805.60

 

1

 

$

8,805.60

 

Occupational therapy

 

97110 x 3

 

48/LE

 

$

183.45

 

48

 

$

8,805.60

 

1

 

$

8,805.60

 

Speech therapy

 

97532 x 3

 

24/LE

 

$

139.32

 

24

 

$

3,343.68

 

1

 

$

3,343.68

 

Neuropsychological testing

 

96102 x 5

 

2/LE

 

$

1,630.65

 

1

 

$

1,630.65

 

2

 

$

3,261.30

 

Head CT scan without contrast

 

70450

 

6/LE

 

$

906.44

 

1

 

$

906.44

 

6

 

$

5,438.64

 

Temporal bone CT scan without contrast

 

70480

 

6/LE

 

$

1,039.74

 

1

 

$

1,039.74

 

6

 

$

6,238.44

 

Facial CT scan without contrast

 

70486

 

6/LE

 

$

986.42

 

1

 

$

986.42

 

6

 

$

5,918.52

 

Facial bone x-rays

 

70150

 

14/LE

 

$

161.62

 

1

 

$

161.62

 

14

 

$

2,262.68

 

Cone beam CT scan with and without contrast

 

70488

 

8/LE

 

$

1,351.66

 

1

 

$

1,351.66

 

8

 

$

10,813.28

 

Sinus x-rays

 

70220

 

14/LE

 

$

185.64

 

1

 

$

185.64

 

14

 

$

2,598.96

 

ENOG testing

 

92516

 

6/LE

 

$

174.90

 

1

 

$

174.90

 

6

 

$

1,049.40

 

EEG

 

95953

 

4/LE

 

$

4,331.00

 

1

 

$

4,331.00

 

4

 

$

17,324.00

 

Cervical CT scan without contrast

 

72125

 

6/LE

 

$

1,346.52

 

1

 

$

1,346.52

 

6

 

$

8,079.12

 

Cervical x-rays

 

72050

 

14/LE

 

$

229.42

 

1

 

$

229.42

 

14

 

$

3,211.88

 

Thoracic CT scan without contrast

 

72128

 

6/LE

 

$

1,343.58

 

1

 

$

1,343.58

 

6

 

$

8,061.48

 

Thoracic x-rays

 

72074

 

14/LE

 

$

215.92

 

1

 

$

215.92

 

14

 

$

3,022.88

 

Chest CT scan without contrast

 

71250

 

6/LE

 

$

1,178.48

 

1

 

$

1,178.48

 

6

 

$

7,070.88

 

Chest x-rays

 

71020

 

14/LE

 

$

146.80

 

1

 

$

146.80

 

14

 

$

2,055.20

 

Pulmonary function tests

 

All Inclusive

 

1/year/LE

 

$

250.00

 

1

 

$

250.00

 

43

 

$

10,750.00

 

Electrodiagnostic testing of diaphragm

 

95866

 

6/LE

 

$

1,117.40

 

1

 

$

1,117.40

 

6

 

$

6,704.40

 

SNIFF test

 

76000

 

6/LE

 

$

274.60

 

1

 

$

274.60

 

6

 

$

1,647.60

 

CMP

 

80053

 

1/year/LE

 

$

81.79

 

1

 

$

81.79

 

43

 

$

3,516.97

 

CBC

 

85025

 

1/year/LE

 

$

43.27

 

1

 

$

43.27

 

43

 

$

1,860.61

 

Levetiracetam level

 

80177

 

1/year/LE

 

$

61.65

 

1

 

$

61.65

 

43

 

$

2,650.95

 

Venipuncture

 

36415

 

1/year/LE

 

$

15.29

 

1

 

$

15.29

 

43

 

$

657.47

 

Pneumococcal vaccine

 

All Inclusive

 

2/LE

 

$

191.92

 

1

 

$

191.92

 

2

 

$

383.84

 

Influenza vaccine

 

All Inclusive

 

1/year/LE

 

$

21.56

 

1

 

$

21.56

 

43

 

$

927.08

 

Portable oxygen system rental

 

E1392

 

12/year/27 years; Medicare coverage for the O2 is only for a total of 3 years
out of every 5 year cycle

 

$

42.16

 

12

 

$

505.92

 

27

 

$

13,659.84

 

Stationary oxygen system rental

 

E1390

 

12/year/27 years; Medicare coverage for the O2 is only for a total of 3 years
out of every 5 year cycle

 

$

86.61

 

12

 

$

1,039.32

 

27

 

$

28,061.64

 

 

--------------------------------------------------------------------------------

 

Spinal cord stimulator revisions

 

All Inclusive

 

6/LE

 

$

30,274.00

 

1

 

$

30,274.00

 

6

 

$

181,644.00

 

Spinal cord stimulator reprogramming

 

All Inclusive

 

2/year/LE

 

$

222.00

 

2

 

$

444.00

 

43

 

$

19,092.00

 

Septoplasty with reduction of the turbinates

 

All Inclusive

 

1/LE

 

$

9,216.00

 

1

 

$

9,216.00

 

1

 

$

9,216.00

 

Tarsorrhaphy, left eye

 

All Inclusive

 

1/LE

 

$

7,109.00

 

1

 

$

7,109.00

 

1

 

$

7,109.00

 

Prosthesis

 

All Inclusive

 

8/LE

 

$

57,013.00

 

1

 

$

57,013.00

 

8

 

$

456,104.00

 

Prosthesis repairs

 

All Inclusive

 

Yearly except for year of replacement

 

$

5,701.30

 

1

 

$

5,701.30

 

35

 

$

199,545.50

 

Stump liners

 

L5673

 

6/year/LE

 

$

695.74

 

6

 

$

4,174.44

 

43

 

$

179,500.92

 

Cosmetic cover

 

All Inclusive

 

1/year/LE

 

$

865.00

 

1

 

$

865.00

 

43

 

$

37,195.00

 

Protective skin

 

All Inclusive

 

1/year/LE

 

$

845.00

 

1

 

$

845.00

 

43

 

$

36,335.00

 

Battery

 

All Inclusive

 

22/LE

 

$

600.00

 

1

 

$

600.00

 

22

 

$

13,200.00

 

Left upper extremity stump x-ray

 

73030

 

22/LE

 

$

146.94

 

1

 

$

146.94

 

22

 

$

3,232.68

 

 

 

 

 

 

 

 

 

 

 

Sub Total:

 

$

1,435,191.48

 

 

This Medicare Set-Aside Cost Projection is composed of future medical needs of
the type normally covered by Medicare over the claimant’s lifetime. Projections
are based on comprehensive review of medical records available at the time of
this report. Costs are based on current state mandated pricing for the state of
jurisdiction or usual and customary charges and no consideration is given for
changes in pricing that may occur in the future. Medications are priced based on
AWP per Redbook.

 

MEDICARE PART D ALLOCATION

 

Medication
B (brand) / G (generic)

 

NDC Code

 

Purpose, Frequency &
Duration of Need

 

Per Unit
Cost

 

# of
units/
month

 

# of
units/
year

 

Annual
Cost

 

Total
# for
LE

 

Total Cost Over
Life Expectancy

 

Fentanyl patches 50mcg/hour (G)

 

00591-3212- 54

 

for pain; #10/month/LE

 

$

23.7500

 

10

 

12

 

$

2,850.00

 

43

 

$

122,550.00

 

Methadone HCL 10mg (G)

 

67877-0116- 01

 

for pain; #270/month/LE

 

$

0.1495

 

270

 

12

 

$

484.38

 

43

 

$

20,828.34

 

Oxycodone 20mg (G)

 

65162-0050- 10

 

for pain; #180/month/LE

 

$

1.1030

 

180

 

12

 

$

2,382.48

 

43

 

$

102,446.64

 

Meloxicam 15mg (G)

 

51991-0419- 01

 

for pain; #30/month/LE

 

$

4.2587

 

30

 

12

 

$

1,533.13

 

43

 

$

65,924.68

 

Zorvolex 35mg (B)

 

42211-0204- 29

 

for pain; #90/month/LE

 

$

3.8640

 

90

 

12

 

$

4,173.12

 

43

 

$

179,444.16

 

Levetiracetam 500mg (G)

 

69102-0101- 01

 

for seizure prophylaxis; #60/month/LE

 

$

0.7800

 

60

 

12

 

$

561.60

 

43

 

$

24,148.80

 

Sertraline HCL 25mg (G)

 

54458-0947- 10

 

for depression/anxiety; #30/month/LE

 

$

2.2650

 

30

 

12

 

$

815.40

 

43

 

$

35,062.20

 

 

 

 

 

 

 

 

 

 

 

 

 

Sub Total:

 

$

550,404.82

 

 

 

 

 

 

 

 

 

 

 

 

 

Grand Total:

 

$

1,985,596.30

 

 

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