| Department File Number : | M201781997 |
| Claim Number : | 160273-1 |
| Date Submitted : | 3/16/2018 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| HEALTH CARE INDEMNITY, INC. | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 61-0904881 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Teresa | Ross | |||
| Street Address | |||||
| One Park Plaza P.O. Box 555 | |||||
| City | State | Zip | |||
| Nashville | TN | 37202 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (615) 344 - 5804 | Teresa.Ross@HCAHealthcare.com | ||||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Carlos | Rodriguez Mendoza | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 315 75th Street W | ||||
| City | State | Zip Code | County | ||
| Bradenton | FL | 34298 | Manatee | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| HCI-10116 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME69006 | Internal Medicine - No Surgery | 01 | |||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Manatee | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Other Location | Heritage Park Care & Rehabilitation Cent | ||||
| Name of Institution | Code | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Other | Nursing Home | ||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 1/15/2016 | 1/11/2017 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Resolving sepsis, UTI, Type 2 diabetes mellitus. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Allege failure to enter orders & direct care of known diabetic to control glucose levels & failure to provide monitoring of glucose level. | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Diabetic complication. | |||||
| 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 | ||||
| *NR | |||||
| County Suit Filed in | Date of Final Disposition | ||||
| *NR | 4/19/2017 | ||||
| Other Defendants Involved in this Claim | |||||
| Marciales, M.D., Werther R | |||||
| 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 | |||||
| 4/7/2017 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $135,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $19,102 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $4,196 | ||||||||||||||||||||
| Injured Person's Total Non-Economic Loss | $45,000 | ||||||||||||||||||||
| Deductible | $0 | ||||||||||||||||||||
| Injured Person's Total Economic Loss | |||||||||||||||||||||
| |||||||||||||||||||||
| Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
| Review of policies and procedures. | |||||||||||||||||||||
| Updates | |||||||||||||
| Date of Change: | 3/16/2018 3:03:13 PM | ||||||||||||
| Reason for Change: | Additional LAE payments made. | ||||||||||||
| |||||||||||||
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. CARLOS RODRIGUEZ MENDOZA, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. CARLOS RODRIGUEZ MENDOZA, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).