Department File Number : | M201884294 |
Claim Number : | C169035 |
Date Submitted : | 2/9/2018 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
ADMIRAL INSURANCE COMPANY | Primary | ||||
Insurer FEIN | Professional License Number | ||||
22-2235730 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Denise | Padilla | |||
Street Address | |||||
1000 Howard Blvd, Ste. 300 | |||||
City | State | Zip | |||
Mount Laurel | NJ | 08054 | |||
Phone | Ext | Fax | E-Mail Address | ||
(856) 505 - 8115 | dpadilla@admiralins.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Evan | S | Jones | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 105 Wedge Circle | ||||
City | State | Zip Code | County | ||
Daytona Beach | FL | 32124 | Volusia | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
AX000005013-02 | $250,000 | $750,000 | |||
Profession or Business | Other Profession or Business | ||||
Registered Nurse | |||||
License Number | Specialty Code & Classification | Certification Number | |||
ARNP9248002 | Additional Charges: Employed Nurse Anesthetists |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | Volusia | ||||
City | State | Zip Code | |||
Location where injury occured | Other location where injury occured | ||||
Other Outpatient Facility | Surgical Center | ||||
Name of Institution | Code | ||||
SURGERY CENTER OF VOLUSIA, LLC | 14960470 | ||||
Location of Institutional Injury | Other Location of Institutional Injury | ||||
Special Procedure Room | |||||
Date of Occurrence | Date Reported to Insurer | ||||
9/15/2016 | 1/31/2017 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
N/A ¿ preventive colonoscopy. | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Colonoscopy | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
*NR | |||||
Principal Injury Giving Rise To The Claim | |||||
Skin tear during post-procedure transfer. | |||||
Severity Of Injury | |||||
Temporary: Slight - Lacerations, contusions, minor scars, rash. No delay. |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 5/16/2017 | ||||
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 | |||||
5/10/2017 |
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $10,000 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $0 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $0 | ||||||||||||||||||||
Injured Person's Total Non-Economic Loss | $0 | ||||||||||||||||||||
Deductible | $1,000 | ||||||||||||||||||||
Injured Person's Total Economic Loss | |||||||||||||||||||||
| |||||||||||||||||||||
Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
None |
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. EVAN S JONES, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. EVAN S JONES, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).