| Department File Number : | M201783396 |
| Claim Number : | 1041095-01 |
| Date Submitted : | 3/8/2018 |
| 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 | DENISE | KLEMCZAK | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 13 Neptune Road | ||||
| City | State | Zip Code | County | ||
| Kissimmee | FL | 34744 | Osceola | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 793175 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Osteopathic Physician | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| OS12104 | Surgery - Obstetrics - Gynecology | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| F | Osceola | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Emergency Room | |||||
| Name of Institution | Code | ||||
| OCALA REGIONAL MEDICAL CENTER | 100212 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Radiology, Emergency Room | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 5/13/2016 | 2/17/2017 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| presented for testing of HCG levels | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| presumed ectopic pregnancy | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| misdiagnosis-negligence | |||||
| Principal Injury Giving Rise To The Claim | |||||
| injection of methotrexate-fetal demise | |||||
| Severity Of Injury | |||||
| Temporary: Slight - Lacerations, contusions, minor scars, rash. No delay. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| *NR | |||||
| County Suit Filed in | Date of Final Disposition | ||||
| *NR | 10/9/2017 | ||||
| Other Defendants Involved in this Claim | |||||
| Poincianna Regional Medical Center Osceola Regional Medical Center Florida Hospital Celebration Health Osceola OB/GYN PA | |||||
| Stage of Legal System at which Settlement was Reached or Award Made | |||||
| Claim or suit abandoned. | |||||
| Final Method of Claim Disposition | |||||
| Dropped before Action Filed | |||||
| Court Decision | Other | ||||
| No Court Proceedings. | |||||
| Arbitration | |||||
| Claim not subject to Arbitration. | |||||
| Date of Payment | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | No | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $0 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $4,884 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $3,877 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| n/a | |||||||||||||||||||||
| Updates | ||||||||||||||||
| Date of Change: | 3/8/2018 8:34:36 AM | |||||||||||||||
| Reason for Change: | Changed patient address | |||||||||||||||
| ||||||||||||||||
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. DENISE KLEMCZAK, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. DENISE KLEMCZAK, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).