Department File Number : | M201575438 |
Claim Number : | SAM-IG-006598 |
Date Submitted : | 8/4/2015 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
SAMARITAN RISK RETENTION GROUP, INC. | Primary | ||||
Insurer FEIN | Professional License Number | ||||
20-3433505 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | NANCY | CARR | |||
Street Address | |||||
11440 SW 88th STREET | |||||
City | State | Zip | |||
MIAMI | FL | 33176 | |||
Phone | Ext | Fax | E-Mail Address | ||
(305) 274 - 4070 | (305) 274 - 2701 | carol.lobacz@nccrms.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Juan | Mantilla | |||
Insurer Type | Street Address of Practice | ||||
Licensed | 8501 S.W. 124th Avenue, Suite 202 | ||||
City | State | Zip Code | County | ||
Miami | FL | 33183 | Dade | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
SPL 1062 | $250,000 | $750,000 | |||
Profession or Business | Other Profession or Business | ||||
Medical Doctor | |||||
License Number | Specialty Code & Classification | Certification Number | |||
ME77038 | Internal Medicine - No Surgery |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | 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 | ||||
Other | Physician's office | ||||
Date of Occurrence | Date Reported to Insurer | ||||
7/14/2009 | 4/1/2015 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Metastatic thymic carcinoma. | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
There was no operation, diagnostic or treatment procedure causing injury. | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
There was no misdiagnosis made of this patient. | |||||
Principal Injury Giving Rise To The Claim | |||||
Patient had a chest x-ray in 2009 as part of pre-operative clearance that demonstrated a prominence of the azygous knob in the right hilar region. A CT was recommended. Due to a clerical error in the office, the CT was never performed. Four years later the patient was diagnosed with metastatic thymic carcinoma. This case was settled without an admission of liability and in order to avoid excess exposure to this physician. | |||||
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 | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 6/26/2015 | ||||
Other Defendants Involved in this Claim | |||||
Stage of Legal System at which Settlement was Reached or Award Made | |||||
Within the pre-suit period as set forth in 766.106 (more than 90 days before suit is filed). | |||||
Final Method of Claim Disposition | |||||
Settled by parties | |||||
Court Decision | Other | ||||
No Court Proceedings. | |||||
Arbitration | |||||
Claim not subject to Arbitration. | |||||
Date of Payment | |||||
6/26/2015 |
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $250,000 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $10,608 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $1,428 | ||||||||||||||||||||
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 | |||||||||||||||||||||
Not applicable. |
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. JUAN MANTILLA, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. JUAN MANTILLA, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).