Department File Number : M201885879 Claim Number : 159103 Date Submitted : 7/12/2018
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 Christina J Stoker Street Address 1100 Charlotte Ave, Ste 500 City State Zip Nashville TN 37203 Phone Ext Fax E-Mail Address (615) 344 - 1779 (615) 344 - 5889 firstname.lastname@example.org
Insured Information Type First Name MI Last Name Individual Lee T WINANS Insurer Type Street Address of Practice Licensed 1700 SOUTH 23RD STREET City State Zip Code County FORT PIERCE FL 34950 St. Lucie Policy Number Per Claim Policy Limits Aggregate Policy Limits HCI-10114 $1,000,000 $3,000,000 Profession or Business Other Profession or Business Medical Doctor License Number Specialty Code & Classification Certification Number ME98688 Emergency Medicine - No Major Surgery
Injured Person Information First Name MI Last Name Date of Birth Street Address Gender County where Injury Occurred M St. Lucie City State Zip Code Location where injury occured Other location where injury occured Emergency Room Name of Institution Code LAWNWOOD REG. MED. CTR 100246 Location of Institutional Injury Other Location of Institutional Injury Other EMERGENCY ROOM Date of Occurrence Date Reported to Insurer 2/6/2014 8/19/2016
Diagnostic Information Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition PATIENT PRESENTED FOLLOWING A FALL FROM 20 FEET WHILE AT WORK. Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury DIAGNOSED WITH LEFT C1,C5,C6 LATERAL MASS FRACTURED, C6 SPINOUS PROCESS FRACTURE AND RIGHT HAND MIDDLE PHALANX FRACTURE OF 3RD FINGER. FRACTURES DEEMED STABLE AND PATIENT DISCHARGED IN CERVICAL COLLAR. Diagnostic Code : Misdiagnosis Made, If Any, Of Patient's Actual Condition *NR Principal Injury Giving Rise To The Claim FAILURE TO DIAGNOSE AND TREAT SPINAL CORD INJURY AND EPIDURAL ABSCESS, RESULTING IN PARAPLEGIA. Severity Of Injury Permanent: Major - Paraplegia, blindness, loss of two limbs, brain damage.
Legal Information Date of Suit Circuit Court Case Number 1/13/2017 2016-CA-001815 County Suit Filed in Date of Final Disposition St. Lucie 6/29/2018 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 No Payment Made Court Decision Other Other DISMISSED PRIOR TO SETTLEMENT. 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 $43,805 All Other Loss Adjustment Expense Paid $8,197 Injured Person's Total Non-Economic Loss $0 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 staff reeducation and reinforcement of policy and procedure
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