Department File Number : | M201885717 |
Claim Number : | 59478 |
Date Submitted : | 6/22/2018 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
MAG MUTUAL INSURANCE COMPANY | Primary | ||||
Insurer FEIN | Professional License Number | ||||
58-1449198 | |||||
Insurer Contact Information | |||||
Type | Entity Name | ||||
Entity | MAG MUTUAL INSURANCE COMPANY | ||||
Street Address | |||||
8427 South Park Circle Suite 130 | |||||
City | State | Zip | |||
Orlando | FL | 32819 | |||
Phone | Ext | Fax | E-Mail Address | ||
(407) 370 - 3813 | (404) 842 - 3319 | ctschanz@magmutual.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Clarisol | M | Martinez | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 13607 Pine Villa Lane | ||||
City | State | Zip Code | County | ||
Fort Myers | FL | 33912 | Lee | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
PRF 1413763 00 | $500,000 | $1,500,000 | |||
Profession or Business | Other Profession or Business | ||||
Medical Doctor | |||||
License Number | Specialty Code & Classification | Certification Number | |||
ME86060 | Internal Medicine - No Surgery |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | Alachua | ||||
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 | ||||
Patients' Room | |||||
Date of Occurrence | Date Reported to Insurer | ||||
5/15/2014 | 10/3/2016 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Hypertension | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Prescribed Lisinopril | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
Alleged failure to properly communicate or follow-up on suspected reaction to Lisinopril | |||||
Principal Injury Giving Rise To The Claim | |||||
Severe reaction/prolonged hospitalization | |||||
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 | ||||
2/24/2017 | 2017-CA-000698 | ||||
County Suit Filed in | Date of Final Disposition | ||||
Alachua | 6/7/2018 | ||||
Other Defendants Involved in this Claim | |||||
Pernice, MD, Mercedes T SIMED | |||||
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 | |||||
5/23/2018 |
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $75,000 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $70,307 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $40,865 | ||||||||||||||||||||
Injured Person's Total Non-Economic Loss | $0 | ||||||||||||||||||||
Deductible | $0 | ||||||||||||||||||||
Injured Person's Total Economic Loss | |||||||||||||||||||||
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Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
Risk management has counseled insured |
Updates | |
No updates found. |
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Department File Number : | M201679760 |
Claim Number : | 54942 |
Date Submitted : | 11/9/2016 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
MAG MUTUAL INSURANCE COMPANY | Primary | ||||
Insurer FEIN | Professional License Number | ||||
58-1449198 | |||||
Insurer Contact Information | |||||
Type | Entity Name | ||||
Entity | MAG MUTUAL INSURANCE COMPANY | ||||
Street Address | |||||
8427 South Park Circle Suite 130 | |||||
City | State | Zip | |||
Orlando | FL | 32819 | |||
Phone | Ext | Fax | E-Mail Address | ||
(407) 370 - 3813 | (407) 370 - 2247 | ctschanz@magmutual.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Clarisol | M | Martinez | ||
Insurer Type | Street Address of Practice | ||||
Licensed | PO Box 357010 | ||||
City | State | Zip Code | County | ||
Gainesville | FL | 32635 | Alachua | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
PRF 1413763 00 | $500,000 | $150,000 | |||
Profession or Business | Other Profession or Business | ||||
Medical Doctor | |||||
License Number | Specialty Code & Classification | Certification Number | |||
ME86060 | Internal Medicine - No Surgery |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | Alachua | ||||
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 | ||||
Patients' Room | |||||
Date of Occurrence | Date Reported to Insurer | ||||
8/19/2013 | 10/6/2015 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Pelvic cyst | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
No iatrogenic injury | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
Alleged failure to timely follow-up on CT of abdomen | |||||
Principal Injury Giving Rise To The Claim | |||||
Delay in treatment of pelvic cyst | |||||
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 | ||||
1/28/2016 | 01-2016-CA-000330 | ||||
County Suit Filed in | Date of Final Disposition | ||||
Alachua | 10/24/2016 | ||||
Other Defendants Involved in this Claim | |||||
Southeastern Primary Care | |||||
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 | |||||
9/14/2016 |
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $65,000 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $20,147 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $6,858 | ||||||||||||||||||||
Injured Person's Total Non-Economic Loss | $0 | ||||||||||||||||||||
Deductible | $0 | ||||||||||||||||||||
Injured Person's Total Economic Loss | |||||||||||||||||||||
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Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
Risk management has counseled insured |
Updates | |||||||
Date of Change: | 11/9/2016 2:39:12 PM | ||||||
Reason for Change: | Report updated to reflect Court Document final disposition date of 10/24/16 | ||||||
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Does Dr. CLARISOL M MARTINEZ, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. CLARISOL M MARTINEZ, MD has at least 2 medical malpractice case(s), lawsuit(s), or complaint(s).