| Department File Number : | M201677771 |
| Claim Number : | 144266 |
| Date Submitted : | 4/1/2016 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| MEDICUS INSURANCE COMPANY | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 20-5623491 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Dionysia | Lawson | |||
| Street Address | |||||
| 560 Davis Street | |||||
| City | State | Zip | |||
| San Francisco | CA | 94111 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (415) 735 - 2013 | (415) 735 - 2097 | dlawson@norcalmutual.com | |||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Munsif | Ali | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 18550 Us Hwy 441 | ||||
| City | State | Zip Code | County | ||
| Mount Dora | FL | 32757 | Citrus | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| FL-16116278 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME111803 | Internal Medicine - Minor Surgery | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Citrus | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Other Location | Outside of PCP's office | ||||
| Name of Institution | Code | ||||
| CITRUS MEMORIAL HOSPITAL | 100023 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Patients' Room | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 7/1/2013 | 6/22/2015 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Estate of 73-year-old male Coumadin patient, with history of head trauma, alleges failure to order repeat CT Scan of head within 12-24 hours after initial study and negligent administration of heparin resulting in intracranial bleed. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| CT Scan of head | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Estate of 73-year-old male Coumadin patient, with history of head trauma, alleges failure to order repeat CT Scan of head within 12-24 hours after initial study and negligent administration of heparin resulting in intracranial bleed. | |||||
| Severity Of Injury | |||||
| Permanent: Death. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| *NR | |||||
| County Suit Filed in | Date of Final Disposition | ||||
| *NR | 1/7/2016 | ||||
| Other Defendants Involved in this Claim | |||||
| Shenai, Nisha Rasheed, Ameer Z |
|||||
| 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 | $5,522 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $2,274 | ||||||||||||||||||||
| Injured Person's Total Non-Economic Loss | $0 | ||||||||||||||||||||
| Deductible | $0 | ||||||||||||||||||||
| Injured Person's Total Economic Loss | |||||||||||||||||||||
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| Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
| Insured met conferenced with Calims Specialist and Defense Attorney | |||||||||||||||||||||
| Updates | |
| No updates found. |
*NR: Prior to 04/28/1999 this field was not required in submitted claims.
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