| Department File Number : | M201885028 |
| Claim Number : | 361965 |
| Date Submitted : | 4/12/2018 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| DOCTORS COMPANY, AN INTERINSURANCE EXCHANGE (THE) | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 95-3014772 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Kelly | Andrews | |||
| Street Address | |||||
| 12724 Gran Bay Parkway, W., Suite 400 | |||||
| City | State | Zip | |||
| Jacksonville | FL | 32258 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (904) 360 - 3038 | kandrews@thedoctors.com | ||||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Faiyaaz | M | Jhaveri | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 2217 North Blvd. West | ||||
| City | State | Zip Code | County | ||
| Davenport | FL | 33837 | Polk | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 0954434 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME80612 | Urology - no surgery | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| F | Polk | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Hospital Inpatient Facility | |||||
| Name of Institution | Code | ||||
| HEART OF FLORIDA REGIONAL MEDICAL CENTER | 100137 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Operating Suite | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 5/23/2017 | 10/23/2017 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Staghorn calculi encrusted J stent chronic and ongoing nephritis/urinary tract infection, hematuria obesity uncontrolled diabetes. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Laparoscopic nephrectomy due to right renal staghorn calculus with calcified indwelling stent with possibility of conversion to open procedure when major blood vessel ligation noted. | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Death of 55 year old married female with one statutory minor living at home. | |||||
| Severity Of Injury | |||||
| Permanent: Death. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| *NR | |||||
| County Suit Filed in | Date of Final Disposition | ||||
| *NR | 3/13/2018 | ||||
| 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 | |||||
| 3/13/2018 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $250,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $8,624 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $6,323 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| Insurance company staff consulted with insured to discuss preventative measures. Patient Safety referral is made if appropriate. | |||||||||||||||||||||
| 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. FAIYAAZ M JHAVERI, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. FAIYAAZ M JHAVERI, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).