Department File Number : | M201886929 |
Claim Number : | 2018-127111 |
Date Submitted : | 11/6/2018 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
NATIONAL UNION FIRE INSURANCE CO. OF PITTSBURGH, PA | Primary | ||||
Insurer FEIN | Professional License Number | ||||
25-0687550 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Connie | L | Peters | ||
Street Address | |||||
PO Box 52810 | |||||
City | State | Zip | |||
Bellevue | WA | 98015 | |||
Phone | Ext | Fax | E-Mail Address | ||
(425) 636 - 1000 | 1012 | (916) 781 - 5795 | cpeters@intercareins.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | EVELYN | RAMIREZ- LEE | |||
Insurer Type | Street Address of Practice | ||||
Licensed | 3220 Forum Blvd., #204 | ||||
City | State | Zip Code | County | ||
Fort Myers | FL | 33905 | Lee | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
DNU064842255 | $1,000,000 | $3,000,000 | |||
Profession or Business | Other Profession or Business | ||||
Dentistry | |||||
License Number | Specialty Code & Classification | Certification Number | |||
DN21223 | Dental General Practice - NOC | 80211 |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
M | Lee | ||||
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 | ||||
Other | Dental Treatment Room | ||||
Date of Occurrence | Date Reported to Insurer | ||||
9/22/2017 | 6/27/2018 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Patient present with severe decay on several teeth and pain at #13. | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Insured provided RCT and crown treatment on #13. Several teeth still had decay that needed treating | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
No misdiagnosis | |||||
Principal Injury Giving Rise To The Claim | |||||
Allegations that the crown broke and the insured placed it negligently knowing it would break | |||||
Severity Of Injury | |||||
Emotional Only - Fright, no physical damage |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 10/31/2018 | ||||
Other Defendants Involved in this Claim | |||||
Stage of Legal System at which Settlement was Reached or Award Made | |||||
Claim or suit abandoned. | |||||
Final Method of Claim Disposition | |||||
No Payment Made | |||||
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 | $0 | ||||||||||||||||||||
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 | |||||||||||||||||||||
No safety management steps taken |
Updates | |
No updates found. |
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. EVELYN RAMIREZ- LEE, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. EVELYN RAMIREZ- LEE, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).