Department File Number : | M201472673 |
Claim Number : | 2011-108717 |
Date Submitted : | 11/14/2014 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
NATIONAL UNION FIRE INSURANCE CO. OF PITTSBURGH, PA | Primary | ||||
Insurer FEIN | Professional License Number | ||||
25-0687550 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Connie | L | Peters | ||
Street Address | |||||
PO Box 52810 | |||||
City | State | Zip | |||
Bellevue | WA | 98015 | |||
Phone | Ext | Fax | E-Mail Address | ||
(425) 636 - 1000 | 1012 | (916) 781 - 5795 | cpeters@intercareins.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Ali | M | Eetessam | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 1575 Pine Ridge Rd., Ste 18 | ||||
City | State | Zip Code | County | ||
Naples | FL | 34109 | Collier | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
DNU 018149936 | $1,000,000 | $3,000,000 | |||
Profession or Business | Other Profession or Business | ||||
Dentistry | |||||
License Number | Specialty Code & Classification | Certification Number | |||
DN14988 | Dental General Practice - NOC | 80211 |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | Collier | ||||
City | State | Zip Code | |||
Location where injury occured | Other location where injury occured | ||||
Physician's Office | |||||
Name of Institution | Code | ||||
Location of Institutional Injury | Other Location of Institutional Injury | ||||
Other | Dental Treatment Room | ||||
Date of Occurrence | Date Reported to Insurer | ||||
7/21/2010 | 4/19/2011 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Plaintiff presented with ultiple areas of decay throughout her mouth and damage to the enamel on teeth #'s6-11 | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Crowns were placed on #'s3-13 | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
No misdiagnosis | |||||
Principal Injury Giving Rise To The Claim | |||||
Plaintiff alleged that the teeth were over prepped and that the crowns were too bulky and irritated her gums. The crowns were replaced. | |||||
Severity Of Injury | |||||
Temporary: Minor - Infections, misset fracture, fall in hospital. Recovery delayed. |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
7/2/2012 | 12-CA-2470 | ||||
County Suit Filed in | Date of Final Disposition | ||||
Collier | 11/10/2014 | ||||
Other Defendants Involved in this Claim | |||||
Stage of Legal System at which Settlement was Reached or Award Made | |||||
More than 90 days, after suit filed and prior to or during the course of mandatory settlement conference. | |||||
Final Method of Claim Disposition | |||||
Settled by parties | |||||
Court Decision | Other | ||||
No Court Proceedings. | |||||
Arbitration | |||||
Claim not subject to Arbitration. | |||||
Date of Payment | |||||
11/10/2014 |
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $150,000 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $68,989 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $12,607 | ||||||||||||||||||||
Injured Person's Total Non-Economic Loss | $109,112 | ||||||||||||||||||||
Deductible | $0 | ||||||||||||||||||||
Injured Person's Total Economic Loss | |||||||||||||||||||||
| |||||||||||||||||||||
Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
No safety management steps taken |
Updates | |
No updates found. |
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Department File Number : | M201989627 |
Claim Number : | 1050715-01 |
Date Submitted : | 2/7/2020 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
FLORIDA MEDICAL MALPRACTICE JUA | Primary | ||||
Insurer FEIN | Professional License Number | ||||
59-1625412 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Lynn | Louthan | |||
Street Address | |||||
5814 Reed Road | |||||
City | State | Zip | |||
Ft Wayne | IN | 46835 | |||
Phone | Ext | Fax | E-Mail Address | ||
(260) 486 - 0778 | (260) 486 - 0782 | Lynn.Louthan@MEDPRO.COM |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Ali | M | Eetessam | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 1575 Pine Ridge Road #18 | ||||
City | State | Zip Code | County | ||
Naples | FL | 34109 | Collier | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
FL010840 | $100,000 | $300,000 | |||
Profession or Business | Other Profession or Business | ||||
Dentistry | |||||
License Number | Specialty Code & Classification | Certification Number | |||
DN14988 | Dentists - NOC classification. |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | Collier | ||||
City | State | Zip Code | |||
Location where injury occured | Other location where injury occured | ||||
Physician's Office | |||||
Name of Institution | Code | ||||
Location of Institutional Injury | Other Location of Institutional Injury | ||||
Date of Occurrence | Date Reported to Insurer | ||||
4/15/2016 | 10/12/2017 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Lower interior teeth #24 & #25 not in place | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
One implant and Invisiline | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
Negligent medical procedure | |||||
Principal Injury Giving Rise To The Claim | |||||
Patient did not follow Invisiline treatment resulting in implant failure | |||||
Severity Of Injury | |||||
Temporary: Slight - Lacerations, contusions, minor scars, rash. No delay. |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
2/7/2018 | 18-320-CA | ||||
County Suit Filed in | Date of Final Disposition | ||||
Collier | 8/5/2019 | ||||
Other Defendants Involved in this Claim | |||||
Stage of Legal System at which Settlement was Reached or Award Made | |||||
More than 90 days, after suit filed and prior to or during the course of mandatory settlement conference. | |||||
Final Method of Claim Disposition | |||||
Settled by parties | |||||
Court Decision | Other | ||||
No Court Proceedings. | |||||
Arbitration | |||||
Claim not subject to Arbitration. | |||||
Date of Payment | |||||
8/2/2019 |
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $55,000 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $25,839 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $18,497 | ||||||||||||||||||||
Injured Person's Total Non-Economic Loss | $44,000 | ||||||||||||||||||||
Deductible | $0 | ||||||||||||||||||||
Injured Person's Total Economic Loss | |||||||||||||||||||||
| |||||||||||||||||||||
Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
n/a |
Updates | |
No updates found. |
Does Dr. ALI M EETESSAM, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. ALI M EETESSAM, MD has at least 2 medical malpractice case(s), lawsuit(s), or complaint(s).