Department File Number : | M201781755 |
Claim Number : | F14-0095-A-13 |
Date Submitted : | 4/7/2017 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
FD INSURANCE COMPANY | Primary | ||||
Insurer FEIN | Professional License Number | ||||
20-3704679 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | jason | haynie | |||
Street Address | |||||
4651 Salisbury Rd., Ste. 410 | |||||
City | State | Zip | |||
Jacksonville | FL | 32256 | |||
Phone | Ext | Fax | E-Mail Address | ||
(904) 296 - 2887 | jhaynie@norcal-group.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Tom | Porter | |||
Insurer Type | Street Address of Practice | ||||
Licensed | 141 Webb Dr, Ste 300 | ||||
City | State | Zip Code | County | ||
Davenport | FL | 33837 | Polk | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
MS000876 | $250,000 | $750,000 | |||
Profession or Business | Other Profession or Business | ||||
Medical Doctor | |||||
License Number | Specialty Code & Classification | Certification Number | |||
ME78730 | Anesthesiology - Pain Management |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
M | Polk | ||||
City | State | Zip Code | |||
Location where injury occured | Other location where injury occured | ||||
Other Location | Lakes Radiology | ||||
Name of Institution | Code | ||||
N/A | 000000 | ||||
Location of Institutional Injury | Other Location of Institutional Injury | ||||
Other | Lakes Radiology | ||||
Date of Occurrence | Date Reported to Insurer | ||||
12/26/2013 | 5/13/2014 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Lumbar transforaminal epidural corticosteriod injection | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Lumbar transforaminal epidural corticosteriod injection | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
Pain not treated | |||||
Principal Injury Giving Rise To The Claim | |||||
Lower back pain | |||||
Severity Of Injury | |||||
Emotional Only - Fright, no physical damage |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 2/28/2017 | ||||
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 | $8,355 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $0 | ||||||||||||||||||||
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 | |||||||||||||||||||||
Discussed with Insured and Risk Managment |
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. TOM PORTER, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. TOM PORTER, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).