| Department File Number : | M201472508 |
| Claim Number : | FP4266201 |
| Date Submitted : | 12/10/2014 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| FIRST PROFESSIONALS INSURANCE COMPANY, INC | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 59-6614702 | |||||
| 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 | Harry | Black | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 1340 Ridgewood Avenue | ||||
| City | State | Zip Code | County | ||
| Holly Hill | FL | 32117 | Volusia | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| FP-CL098490 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME48766 | Surgery - General | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Volusia | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Hospital Inpatient Facility | |||||
| Name of Institution | Code | ||||
| HALIFAX MEDICAL CENTER | 100017 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Operating Suite | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 6/23/2010 | 1/26/2012 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Thyroid cancer papillary carcinoma. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Total thyroidectomy. | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Bilateral lacerations of patients vocal cords. | |||||
| 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 | ||||
| 1/7/2013 | 2012-33280 CICI | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Volusia | 10/24/2014 | ||||
| Other Defendants Involved in this Claim | |||||
| Florida Healthcare Plans, Inc. | |||||
| 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 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $725,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $65,297 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $35,204 | ||||||||||||||||||||
| 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 | |||||||||||||
| Date of Change: | 12/10/2014 10:38:26 AM | ||||||||||||
| Reason for Change: | Correction to injury location. | ||||||||||||
| |||||||||||||
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. HARRY BLACK, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. HARRY BLACK, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).