| Department File Number : | M201573407 |
| Claim Number : | HMA38611 |
| Date Submitted : | 2/6/2015 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| COLUMBIA CASUALTY COMPANY | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 47-0490411 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Juanetta | J | Moore | ||
| Street Address | |||||
| 333. Wabash Ave | |||||
| City | State | Zip | |||
| Chicago | IL | 60685 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (312) 822 - 3353 | Juanetta.Moore@cna.com | ||||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Jordan | Teder | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 9011 Daniels PKWY Suite 105 | ||||
| City | State | Zip Code | County | ||
| Fort Myers | FL | 33912 | Lee | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| SLD 4022675190 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Dentistry | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| DN20204 | Dentists | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| F | 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 | ||||
| Special Procedure Room | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 3/13/2014 | 12/11/2014 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Fillings on lower teeth | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| crown replacement | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Alleged failed amalgam, restorations had to be redone | |||||
| Severity Of Injury | |||||
| Temporary: Minor - Infections, misset fracture, fall in hospital. Recovery delayed. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 12/4/2014 | 14-SC-004244 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Lee | 1/13/2015 | ||||
| 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 | |||||||||||||||||||||
| Insured discussed case with defense counsel and insurance personnel | |||||||||||||||||||||
| 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. JORDAN TEDER, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. JORDAN TEDER, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).