| Department File Number : | M201783416 |
| Claim Number : | 7012055 |
| Date Submitted : | 5/2/2018 |
| 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 | Florence | R | Marafatsos | ||
| Street Address | |||||
| 6133 N River Road | |||||
| City | State | Zip | |||
| Rosemont | IL | 60018 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (800) 522 - 6675 | 8466 | (847) 653 - 8486 | florence.marafatsos@fortressins.com | ||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Axel | Martinez-Negron | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 2654 N. Andrews Ave., Suite 4 | ||||
| City | State | Zip Code | County | ||
| Wilton Manors | FL | 33311 | Broward | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 33527 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Dentistry | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| DN14509 | Dentists | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Broward | ||||
| 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 | ||||
| 8/29/2013 | 8/18/2014 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Longtime patient of the insured with multiple preexisting medical conditions presented for an implant at tooth site #19. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| The insured placed an implant at site #19. | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Plaintiff alleged insured negligently placed implants for #19 and #30 and failed to diagnose osteomyelitis and implant failure leading to surgical resection of necrotic bone and reconstruction of his mandible. | |||||
| Severity Of Injury | |||||
| Temporary: Minor - Infections, misset fracture, fall in hospital. Recovery delayed. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 8/29/2015 | CACE-15-015469 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Broward | 10/9/2017 | ||||
| Other Defendants Involved in this Claim | |||||
| Stage of Legal System at which Settlement was Reached or Award Made | |||||
| After court verdict and prior to filing of notice of appeal. | |||||
| Final Method of Claim Disposition | |||||
| Settled by parties | |||||
| Court Decision | Other | ||||
| Other | Settled | ||||
| Arbitration | |||||
| Claim not subject to Arbitration. | |||||
| Date of Payment | |||||
| 10/6/2017 | |||||
| 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 | $105,573 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $27,144 | ||||||||||||||||||||
| 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 | |||||||
| Date of Change: | 10/26/2017 11:39:09 AM | ||||||
| Reason for Change: | Court Decision correction | ||||||
| |||||||
| Date of Change: | 5/2/2018 1:47:54 PM | ||||||
| Reason for Change: | The severity was incorrectly reported as Permanent Major and has been updated to Permanent Minor. | ||||||
| |||||||
| Date of Change: | 5/2/2018 2:33:06 PM | ||||||
| Reason for Change: | I had selected the wrong coding TEMPORARY: MAJOR is the proper coding | ||||||
| |||||||
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. AXEL MARTINEZ-NEGRON, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. AXEL MARTINEZ-NEGRON, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).