Department File Number : | M201472196 |
Claim Number : | 2014-116954 |
Date Submitted : | 9/29/2014 |
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 | Deepa | Mehta | |||
Insurer Type | Street Address of Practice | ||||
Licensed | 1301 South International Pkwy, Ste 2041 | ||||
City | State | Zip Code | County | ||
Lake Mary | FL | 32745 | Seminole | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
DNU 065089456 | $1,000,000 | $3,000,000 | |||
Profession or Business | Other Profession or Business | ||||
Dentistry | |||||
License Number | Specialty Code & Classification | Certification Number | |||
DN16919 | Dentists - N.O.C. | 80211 |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | Seminole | ||||
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 | ||||
1/30/2014 | 6/2/2014 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Claimant presented to the insured for a new full upper and lower implant supported denture | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Insured comleted the upper and lower denture and was in the process of seating. | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
No misdiagnosis | |||||
Principal Injury Giving Rise To The Claim | |||||
after seating the overdenture insured was removing an "o" ring when the titanium bar which was placed in 1980 with a subperiostal blade implant broke. | |||||
Severity Of Injury | |||||
Emotional Only - Fright, no physical damage |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 9/27/2014 | ||||
Other Defendants Involved in this Claim | |||||
Stage of Legal System at which Settlement was Reached or Award Made | |||||
Claim or suit abandoned. | |||||
Final Method of Claim Disposition | |||||
No Payment Made | |||||
Court Decision | Other | ||||
No Court Proceedings. | |||||
Arbitration | |||||
Claim not subject to Arbitration. | |||||
Date of Payment | |||||
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | No | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $0 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $0 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $0 | ||||||||||||||||||||
Injured Person's Total Non-Economic Loss | $0 | ||||||||||||||||||||
Deductible | $0 | ||||||||||||||||||||
Injured Person's Total Economic Loss | |||||||||||||||||||||
| |||||||||||||||||||||
Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
No safety managment steps taken. |
Updates | |
No updates found. |
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. DEEPA MEHTA, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. DEEPA MEHTA, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).