Department File Number : | M201677871 |
Claim Number : | 156337-3 |
Date Submitted : | 2/20/2017 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
HEALTH CARE INDEMNITY, INC. | Primary | ||||
Insurer FEIN | Professional License Number | ||||
61-0904881 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Teresa | Ross | |||
Street Address | |||||
One Park Plaza P.O. Box 555 | |||||
City | State | Zip | |||
Nashville | TN | 37202 | |||
Phone | Ext | Fax | E-Mail Address | ||
(615) 344 - 5804 | Teresa.Ross@HCAHealthcare.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Keri | Davies | |||
Insurer Type | Street Address of Practice | ||||
Licensed | 11373 Cortez Blvd. Suite 301 | ||||
City | State | Zip Code | County | ||
Brooksville | FL | 34613 | Hernando | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
HCI-10115 | $250,000 | $750,000 | |||
Profession or Business | Other Profession or Business | ||||
Other | Nurse Practitioner | ||||
License Number | Specialty Code & Classification | Certification Number | |||
ARNP9263482 |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
M | Hernando | ||||
City | State | Zip Code | |||
Location where injury occured | Other location where injury occured | ||||
Hospital Inpatient Facility | |||||
Name of Institution | Code | ||||
OAK HILL HOSPITAL | 100264 | ||||
Location of Institutional Injury | Other Location of Institutional Injury | ||||
Operating Suite | |||||
Date of Occurrence | Date Reported to Insurer | ||||
1/5/2015 | 9/23/2015 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Benign malignancy, intestinal disorder. | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Patient underwent transverse colectomy resulting in injury to spleen requiring follow up procedure which resulted in retained sponge. | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
*NR | |||||
Principal Injury Giving Rise To The Claim | |||||
Retained sponge, injury to spleen. | |||||
Severity Of Injury | |||||
Temporary: Major - Burns, surgical material left, drug side effect, brain damage. Recovery delayed. |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 3/29/2016 | ||||
Other Defendants Involved in this Claim | |||||
Stage of Legal System at which Settlement was Reached or Award Made | |||||
Settlement Reached Prior to Pre-Suit Period | |||||
Final Method of Claim Disposition | |||||
Settled by parties | |||||
Court Decision | Other | ||||
No Court Proceedings. | |||||
Arbitration | |||||
Claim not subject to Arbitration. | |||||
Date of Payment | |||||
3/9/2016 |
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $8,800 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $655 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $170 | ||||||||||||||||||||
Injured Person's Total Non-Economic Loss | $4,400 | ||||||||||||||||||||
Deductible | $0 | ||||||||||||||||||||
Injured Person's Total Economic Loss | |||||||||||||||||||||
| |||||||||||||||||||||
Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
Review of policies and procedures. |
Updates | |||||||||||||
Date of Change: | 2/20/2017 11:07:27 AM | ||||||||||||
Reason for Change: | Additional LAE payments made. | ||||||||||||
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*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. KERI DAVIES, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. KERI DAVIES, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).