| Department File Number : | M201885711 |
| Claim Number : | 67070 |
| Date Submitted : | 6/21/2018 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| ORTHOFORUM INSURANCE COMPANY (A RISK RETENTION GROUP) | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 45-4706502 | |||||
| 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 | Edward | R | Jackson | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 3334 Capital Medical Blvd. | ||||
| City | State | Zip Code | County | ||
| Tallahassee | FL | 32308 | Leon | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| OFIC014-15 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME107624 | Surgery - Orthopedic | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Leon | ||||
| 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 | ||||
| 6/21/2013 | 8/3/2015 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Slipped capital femoral epiphysis | |||||
| 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 diagnose slipped capital femoral epiphysis | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Delay in surgery and need for total hip replacement | |||||
| 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 | ||||
| 12/22/2015 | 2015CA2975 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Leon | 6/14/2018 | ||||
| Other Defendants Involved in this Claim | |||||
| Tallahassee Orthopedic Clinic | |||||
| 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 | |||||
| 6/14/2018 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $375,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $65,755 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $0 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| Risk management has counseled insured | |||||||||||||||||||||
| Updates | |
| No updates found. |
This page is not displaying certain sensitive information.
| Department File Number : | M201885423 |
| Claim Number : | 67076 |
| Date Submitted : | 6/1/2018 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| ORTHOFORUM INSURANCE COMPANY (A RISK RETENTION GROUP) | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 45-4706502 | |||||
| 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 | Edward | R | Jackson | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 3334 Capital Med. Blvd. | ||||
| City | State | Zip Code | County | ||
| Tallahassee | FL | 32308 | Leon | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| OFIC014-16 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME107624 | Surgery - Orthopedic | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Leon | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Hospital Inpatient Facility | |||||
| Name of Institution | Code | ||||
| CAPITAL HEALTH PLAN, INC | 20910007 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Operating Suite | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 4/14/2015 | 3/7/2016 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Advanced end stage arthritis with loss of joint space | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Total arthroplasty of right knee | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| Alleged failure to properly perform procedure | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Revision surgery | |||||
| 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 | ||||
| 5/16/2017 | 2017-CA-001029 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Leon | 5/17/2018 | ||||
| Other Defendants Involved in this Claim | |||||
| Tallahassee Orthopedic Clinic | |||||
| 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 | |||||
| 5/17/2018 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $225,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $29,918 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $0 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| Risk management has counseled insured | |||||||||||||||||||||
| Updates | |
| No updates found. |
This page is not displaying certain sensitive information.
Does Dr. EDWARD R JACKSON, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. EDWARD R JACKSON, MD has at least 2 medical malpractice case(s), lawsuit(s), or complaint(s).