Department File Number : | M201574403 |
Claim Number : | 7006845 |
Date Submitted : | 4/27/2015 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
FORTRESS INSURANCE COMPANY | Primary | ||||
Insurer FEIN | Professional License Number | ||||
36-4159841 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Janet | L | Meyer | ||
Street Address | |||||
6133 North River Road, Suite 650 | |||||
City | State | Zip | |||
Rsoemont | ID | 60018 | |||
Phone | Ext | Fax | E-Mail Address | ||
(847) 653 - 8823 | (847) 653 - 8485 | janet.meyer@fortressins.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Jan | A | Simon | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 13716 SW 84th Street | ||||
City | State | Zip Code | County | ||
Miami | FL | 33183 | Dade | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
32270 | $1,000,000 | $3,000,000 | |||
Profession or Business | Other Profession or Business | ||||
Dentistry | |||||
License Number | Specialty Code & Classification | Certification Number | |||
DN5781 | Dentists |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
M | Dade | ||||
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 | ||||
10/16/2004 | 10/12/2010 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
The patient originally presented in 2004 for orthodontic treatment. At that time he presented with a bilateral cross bite with a narrow upper jaw. | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
The insured following a thorough examination and evaluation propsed a two phase treatment plan. The first phase treatment plan was initiated and completed in 2007. At that time the insured began the second phase of the agreed upon treatment plan. | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
*NR | |||||
Principal Injury Giving Rise To The Claim | |||||
The patient alleged the need for additional surgery due to improper orthodontic care from 2004 thru 2010. | |||||
Severity Of Injury | |||||
Permanent: Significant - Deafness, loss of limb, loss of eye, loss of one kidney or lung. |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
6/11/2012 | 12 22077CA | ||||
County Suit Filed in | Date of Final Disposition | ||||
Dade | 3/27/2015 | ||||
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 | |||||
4/7/2015 |
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $100,000 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $26,202 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $13,783 | ||||||||||||||||||||
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 | |||||||||||||||||||||
Unknown |
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. JAN A SIMON, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. JAN A SIMON, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).