| Department File Number : | M201575887 |
| Claim Number : | 25657 |
| Date Submitted : | 9/24/2015 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| MAG MUTUAL INSURANCE COMPANY | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 58-1449198 | |||||
| Insurer Contact Information | |||||
| Type | Entity Name | ||||
| Entity | MAG MUTUAL INSURANCE COMPANY | ||||
| Street Address | |||||
| 8427 South Park Circle Suite 130 | |||||
| City | State | Zip | |||
| Orlando | FL | 32819 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (407) 370 - 3813 | (407) 370 - 2247 | ctschanz@magmutual.com | |||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Luis | E | Carrillo | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 2129 Phillips Ave. | ||||
| City | State | Zip Code | County | ||
| Lakeland | FL | 33803 | Polk | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| PSL 1600264 07 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME73042 | Internal Medicine - Minor Surgery | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| F | Polk | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Hospital Inpatient Facility | |||||
| Name of Institution | Code | ||||
| Lakeland Regional Medical Center | 100157 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Operating Suite | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 5/4/2006 | 5/29/2007 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Atypical chest pain | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Cardiac catheterization | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| Alleged failure to properly manage patient post-procedure | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Bleeding from right common femoral artery | |||||
| Severity Of Injury | |||||
| Permanent: Death. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 10/30/2008 | 53-2008-CA-001049 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Polk | 9/21/2015 | ||||
| Other Defendants Involved in this Claim | |||||
| Munir, MD, Mohamid Lakeland Regional Medical Center Haider, MD, Kamal Chan-Pong, MD, Jimmy Clark & Daughtrey | |||||
| 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 | |||||
| 9/21/2015 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $325,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $49,612 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $19,292 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| Risk management has counseled insured | |||||||||||||||||||||
| Updates | |
| No updates found. |
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| Department File Number : | M201988772 |
| Claim Number : | 60251 |
| Date Submitted : | 5/15/2019 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| MAG MUTUAL INSURANCE COMPANY | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 58-1449198 | |||||
| Insurer Contact Information | |||||
| Type | Entity Name | ||||
| Entity | MAG MUTUAL INSURANCE COMPANY | ||||
| Street Address | |||||
| 8427 South Park Circle Suite 130 | |||||
| City | State | Zip | |||
| Orlando | FL | 32819 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (407) 370 - 3813 | (404) 842 - 3319 | ctschanz@magmutual.com | |||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Luis | E | Carrillo | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 2129 Phillips Ave. | ||||
| City | State | Zip Code | County | ||
| Lakeland | FL | 33803 | Polk | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| PRF 1413595 00 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME73042 | Cardiovascular Disease - No Surgery | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Polk | ||||
| 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 | ||||
| Patients' Room | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 7/21/2014 | 11/18/2016 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Cardiopulmonary disease | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Prescribed Amiodarone | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| Alleged failure to properly prescribe and monitor Amiodarone therapy | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Cardiopulmonary complications | |||||
| Severity Of Injury | |||||
| Permanent: Death. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 3/7/2018 | 2017-CA-002209-0000- | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Polk | 4/17/2019 | ||||
| Other Defendants Involved in this Claim | |||||
| Lopez, MD, Raul A Detiquez, MD, Sherrilyn P Clark & Daughtrey Medical Group Kumbham, MD, Anurag R Lakeland Regional Health Cornerstone Medical Care of Brandon | |||||
| 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 | |||||
| 4/17/2019 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $99,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $78,423 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $22,078 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| Risk management has counseled insured | |||||||||||||||||||||
| Updates | |
| No updates found. |
Does Dr. LUIS E CARRILLO, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. LUIS E CARRILLO, MD has at least 2 medical malpractice case(s), lawsuit(s), or complaint(s).