Department File Number : | M201679042 |
Claim Number : | 7030260 |
Date Submitted : | 7/12/2016 |
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 N. River RD., Suite 650 | |||||
City | State | Zip | |||
Rosemont | IL | 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 | Ronald | F | Jacob | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 17 North Old Kings Road, Suite H | ||||
City | State | Zip Code | County | ||
Palm Coast | FL | 32137 | Flagler | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
35539 | $500,000 | $1,000,000 | |||
Profession or Business | Other Profession or Business | ||||
Dentistry | |||||
License Number | Specialty Code & Classification | Certification Number | |||
DN14700 | Dentists |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
M | Flagler | ||||
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 | ||||
6/28/2014 | 9/9/2015 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Implant at site #14. | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Independently contracted dentist, not our insured placed an implant at site #14. | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
*NR | |||||
Principal Injury Giving Rise To The Claim | |||||
Improperly place implant at site #14 had to be removed and requires replacement. | |||||
Severity Of Injury | |||||
Temporary: Minor - Infections, misset fracture, fall in hospital. Recovery delayed. |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 6/28/2016 | ||||
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 | $4,494 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $1,239 | ||||||||||||||||||||
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. RONALD F JACOB, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. RONALD F JACOB, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).