Department File Number : M201886287 Claim Number : GC108432A2014313178 Date Submitted : 8/28/2018
Insurer Information Insurer Name Coverage Type CARE RISK RETENTION GROUP, INC. Primary Insurer FEIN Professional License Number 52-2395338 Insurer Contact Information Type First Name MI Last Name Individual Sarah McIntosh Street Address PO Box 22989 City State Zip Louisville KY 40252 Phone Ext Fax E-Mail Address (502) 708 - 3103 firstname.lastname@example.org
Insured Information Type First Name MI Last Name Individual LAWRENCE S AMESSE Insurer Type Street Address of Practice Licensed 10301 Hagen Ranch Road, #6 City State Zip Code County Boynton Beach FL 33437 Palm Beach Policy Number Per Claim Policy Limits Aggregate Policy Limits PPL0900265 $250,000 $750,000 Profession or Business Other Profession or Business Medical Doctor License Number Specialty Code & Classification Certification Number ME116927 Endocrinology - No Surgery
Injured Person Information First Name MI Last Name Date of Birth Street Address Gender County where Injury Occurred M Palm Beach City State Zip Code Location where injury occured Other location where injury occured Physician's Office Name of Institution Code PALM BEACH GARDENS MEDICAL CENTER 100176 Location of Institutional Injury Other Location of Institutional Injury Special Procedure Room Date of Occurrence Date Reported to Insurer 4/8/2014 1/26/2016
Diagnostic Information Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition Patient sought treatment for erectile dysfunction. Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury An injection of trimix was performed. Diagnostic Code : Misdiagnosis Made, If Any, Of Patient's Actual Condition *NR Principal Injury Giving Rise To The Claim An alleged improper performance of a trimix injection resulting in irreversible and permanent impotence. Subsequently, the patient had a blood clot removed from his penis. In addition, the patient required a penile implant. 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 8/10/2016 502016CA008952 County Suit Filed in Date of Final Disposition Palm Beach 7/13/2018 Other Defendants Involved in this Claim 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 $50,000 Loss Adjust Expense Paid to Defense Counsel $165,213 All Other Loss Adjustment Expense Paid $0 Injured Person's Total Non-Economic Loss $50,500 Deductible $0 Injured Person's Total Economic Loss
Incurred to Date Anticipated Medical Expense $0 $0 Wage Loss $0 $0 Other Expenses $0 $0 Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely Policy in place.
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