| Department File Number : | M201782955 |
| Claim Number : | 6012801 |
| Date Submitted : | 9/5/2017 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| OMS NATIONAL INSURANCE COMPANY, RISK RETENTION GROUP | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 36-3571664 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | jANET | l | mEYER | ||
| Street Address | |||||
| 6133 North River Road, Suite 650 | |||||
| City | State | Zip | |||
| Rosemont | ID | 60018 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (800) 522 - 6670 | (847) 653 - 8486 | janet.meyer@fortressins.com | |||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Barrett | R | Tolley | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 3330 Capitol Oaks Drive | ||||
| City | State | Zip Code | County | ||
| Tallahassee | FL | 32308 | Leon | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 2000385 | $2,000,000 | $6,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Dentistry | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| DN17462 | Dentists - Engaged in oral surgery or operative dentistry on patients rendered unconscious through the administering of any anesthesia or analgesia | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| F | Leon | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Hospital Inpatient Facility | |||||
| Name of Institution | Code | ||||
| Lakeland Regional Medical Center | 100157 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Operating Suite | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 12/4/2012 | 6/5/2015 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Patient presented for consultation regarding congenital facial deformity. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| The insured performed bilateral split osteotomy with mandibular advancement, multi segment LeFort I osteotomy with advancement and impaction of the maxilla and advanced genioplasty. | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Plaintiff alleged a non-union of a fracture post surgical procedure and that the insured failed to address her post operative complications. | |||||
| Severity Of Injury | |||||
| Temporary: Major - Burns, surgical material left, drug side effect, brain damage. Recovery delayed. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 11/17/2015 | 15CA002340 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Leon | 8/21/2017 | ||||
| Other Defendants Involved in this Claim | |||||
| Stage of Legal System at which Settlement was Reached or Award Made | |||||
| More than 90 days, after suit filed and prior to or during the course of mandatory settlement conference. | |||||
| Final Method of Claim Disposition | |||||
| Settled by parties | |||||
| Court Decision | Other | ||||
| No Court Proceedings. | |||||
| Arbitration | |||||
| Claim not subject to Arbitration. | |||||
| Date of Payment | |||||
| 8/25/2017 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $650,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $87,065 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $16,110 | ||||||||||||||||||||
| 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. BARRETT R TOLLEY, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. BARRETT R TOLLEY, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).