| Department File Number : | M201781049 |
| Claim Number : | 6011989 |
| Date Submitted : | 2/23/2017 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| OMS NATIONAL INSURANCE COMPANY, RISK RETENTION GROUP | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 36-3571664 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Janet | L | Meyer | ||
| Street Address | |||||
| 6133 North River Road, Suite 650 | |||||
| City | State | Zip | |||
| Rosemont | IL | 60018 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (800) 522 - 6670 | (847) 653 - 8485 | janet.meyer@fortressins.com | |||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Leslie | Celestina | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 11215 East State Road 70 | ||||
| City | State | Zip Code | County | ||
| Bradenton | FL | 34202 | Manatee | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 24087 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Dentistry | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| DN15545 | Dentists - Engaged in oral surgery or operative dentistry on patients rendered unconscious through the administering of any anesthesia or analgesia | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Highlands | ||||
| 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 | ||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 7/11/2014 | 10/29/2014 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Patient was referred for the extraction of teeth #s 1, 16, 17 and 32. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| The insured extracted teeth #s 1, 16, 18 and 31. | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Patient alleged the insured extracted teeth #s 18 and 31 instead of intended teeth #s 17 and 32. | |||||
| 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 | ||||
| *NR | |||||
| County Suit Filed in | Date of Final Disposition | ||||
| *NR | 1/31/2017 | ||||
| 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 | |||||
| 1/24/2017 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $20,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $10,725 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $1,057 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| Unknown | |||||||||||||||||||||
| Updates | ||||||||||||||||
| Date of Change: | 2/23/2017 1:17:59 PM | |||||||||||||||
| Reason for Change: | Insured's Office location required correction. | |||||||||||||||
| ||||||||||||||||
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. LESLIE CELESTINA, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. LESLIE CELESTINA, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).