| Department File Number : | M201472816 |
| Claim Number : | 43429 |
| Date Submitted : | 12/19/2014 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| MAG MUTUAL INSURANCE COMPANY | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 58-1449198 | |||||
| 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 | (407) 370 - 2247 | ctschanz@magmutual.com | |||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Glen | E | Vanderzalm | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 3885 Oakwater Circle | ||||
| City | State | Zip Code | County | ||
| Orlando | FL | 32806 | Orange | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| PSL 1602883 01 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME91815 | Gastroenterology - Minor Surgery | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Orange | ||||
| 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 | ||||
| 6/22/2011 | 12/17/2012 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| GERD | |||||
| 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 refer patient to cardiologist | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Thrombosis | |||||
| Severity Of Injury | |||||
| Permanent: Death. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 5/23/2013 | 2013-CA-011490-0 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Orange | 12/12/2014 | ||||
| Other Defendants Involved in this Claim | |||||
| Internal Medicine Specialists | |||||
| 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 | |||||
| 11/19/2014 | |||||
| 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 | $18,525 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $9,896 | ||||||||||||||||||||
| 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 | |||||||
| Date of Change: | 12/19/2014 12:06:47 PM | ||||||
| Reason for Change: | Report updated to reflect Court Document final disposition date of 12/12/14. | ||||||
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Does Dr. GLEN E VANDERZALM, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. GLEN E VANDERZALM, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).