| Department File Number : | M201678957 |
| Claim Number : | 1023059-01 |
| Date Submitted : | 2/21/2017 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| MEDICAL PROTECTIVE COMPANY (THE) | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 35-0506406 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Lynn | Louthan | |||
| Street Address | |||||
| 5814 Reed Road | |||||
| City | State | Zip | |||
| Ft Wayne | IN | 46835 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (260) 486 - 0778 | reportaclaim@medpro.com | ||||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | David | A | Mosborg | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 1895 Kingsley Ave, Ste 703 | ||||
| City | State | Zip Code | County | ||
| Orange Park | FL | 32073 | Clay | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 780296 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME61356 | Surgery - Otorhinolaryngology | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Clay | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Hospital Outpatient Facility | |||||
| Name of Institution | Code | ||||
| ORANGE PARK SURGERY CENTER | 146 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Operating Suite | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 12/18/2014 | 12/23/2014 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Chronic nasal congestion | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Nasal septal reconstruction | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| Failure to recognize and timely treat complications from perforations including pneumocephalus | |||||
| Principal Injury Giving Rise To The Claim | |||||
| CSF leak | |||||
| Severity Of Injury | |||||
| Permanent: Significant - Deafness, loss of limb, loss of eye, loss of one kidney or lung. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| *NR | |||||
| County Suit Filed in | Date of Final Disposition | ||||
| *NR | 6/30/2016 | ||||
| Other Defendants Involved in this Claim | |||||
| Stage of Legal System at which Settlement was Reached or Award Made | |||||
| Within the pre-suit period as set forth in 766.106 (more than 90 days before suit is filed). | |||||
| Final Method of Claim Disposition | |||||
| Settled by parties | |||||
| Court Decision | Other | ||||
| No Court Proceedings. | |||||
| Arbitration | |||||
| Claim not subject to Arbitration. | |||||
| Date of Payment | |||||
| 6/28/2016 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $215,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $19,723 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $8,888 | ||||||||||||||||||||
| Injured Person's Total Non-Economic Loss | $81,000 | ||||||||||||||||||||
| Deductible | $0 | ||||||||||||||||||||
| Injured Person's Total Economic Loss | |||||||||||||||||||||
| |||||||||||||||||||||
| Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
| N/A | |||||||||||||||||||||
| Updates | ||||||||||
| Date of Change: | 8/11/2016 11:00:04 AM | |||||||||
| Reason for Change: | ALE UPDATED 8/11/2016 | |||||||||
| ||||||||||
| Date of Change: | 2/21/2017 11:18:52 AM | |||||||||
| Reason for Change: | ALE UPDATE 2/21/2017 | |||||||||
| ||||||||||
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. DAVID A MOSBORG, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. DAVID A MOSBORG, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).