| Department File Number : | M201679318 |
| Claim Number : | CLFL3264A |
| Date Submitted : | 8/2/2016 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| CENTURION MEDICAL LIABILITY PROTECTIVE RISK RETENTION GROUP, INC. | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 20-1145017 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | LETIA | SHELTON | |||
| Street Address | |||||
| 3100 SOUTH GESSNER ROAD SUITE 600 | |||||
| City | State | Zip | |||
| HOUSTON | TX | 77063 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (713) 353 - 1624 | lshelton@proclaimamerica.com | ||||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | ANNETTE | SANTIAGO | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 17105 GULF PINE CIRCLE | ||||
| City | State | Zip Code | County | ||
| WELLINGTON | FL | 33498 | Palm Beach | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| FL3264 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Podiatric Physician | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME106473 | |||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Palm Beach | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Emergency Room | |||||
| Name of Institution | Code | ||||
| PALMS WEST HOSPITAL | 110006 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Patients' Room | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 3/4/2012 | 5/30/2014 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| STEVENS-JOHNSON SYNDROME | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| MISDIAGNOSED FLU | |||||
| Diagnostic Code : | 695.13 | ||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| FLU | |||||
| Principal Injury Giving Rise To The Claim | |||||
| MISDIAGNOSIS/STEVENS-JOHNSON SYNDROME | |||||
| Severity Of Injury | |||||
| Permanent: Minor - Loss of fingers, loss or damage to organs. Includes non-disabling injuries. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 5/30/2014 | 12345678910 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Palm Beach | 6/8/2016 | ||||
| Other Defendants Involved in this Claim | |||||
| Stage of Legal System at which Settlement was Reached or Award Made | |||||
| Settlement Reached Prior to Pre-Suit Period | |||||
| Final Method of Claim Disposition | |||||
| Settled by parties | |||||
| Court Decision | Other | ||||
| No Court Proceedings. | |||||
| Arbitration | |||||
| Claim not subject to Arbitration. | |||||
| Date of Payment | |||||
| 6/8/2016 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $62,500 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $0 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| UNKNOWN | |||||||||||||||||||||
| Updates | |
| No updates found. |
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Does Dr. ANNETTE SANTIAGO, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. ANNETTE SANTIAGO, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).