| Department File Number : | M201679691 |
| Claim Number : | HPT 1466 |
| Date Submitted : | 9/15/2016 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| Gottlich, Malcolm | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 59-128129 | ME57439 | ||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Carol | Wiseheart | |||
| Street Address | |||||
| 747 S. Ridgewood Ave, Suite 111 | |||||
| City | State | Zip | |||
| Daytona Beach | FL | 32114 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (386) 310 - 7969 | (386) 310 - 7973 | cwiseheart@halifaxins.org | |||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Malcolm | Gottlich | |||
| Insurer Type | Street Address of Practice | ||||
| Self-Insurer | 1075 Mason Avenue | ||||
| City | State | Zip Code | County | ||
| Daytona Beach | FL | 32117 | Volusia | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 01-39 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME57439 | Surgery - Orthopedic | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Volusia | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Hospital Inpatient Facility | |||||
| Name of Institution | Code | ||||
| MEMORIAL HOSPITAL - ORMOND BEACH | 100169 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Operating Suite | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 4/13/2011 | 7/22/2013 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Mechanical failure left total hip arthroplasty, osteolysis. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Alleged iatrogenic injury. | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| MRSA | |||||
| Severity Of Injury | |||||
| Temporary: Minor - Infections, misset fracture, fall in hospital. Recovery delayed. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 1/4/2014 | 2013 32617 CICI | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Volusia | 8/29/2016 | ||||
| Other Defendants Involved in this Claim | |||||
| Memorial Hospital Ormond Ameripath Hospital Services FL, LLC Bryan, M.D., James Yee, M.D., John Lagana, ARNP, Anthony Orthopaedic Clinic of Daytona Menezes, MD, Ivan Magnate, Carol Volusia Medical Center Bert Fish Medical Center | |||||
| 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 | ||||
| No Court Proceedings. | |||||
| 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 | $48,380 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $700 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| On going risk management | |||||||||||||||||||||
| Updates | |||||||
| Date of Change: | 9/15/2016 3:39:42 PM | ||||||
| Reason for Change: | mistyped field entry | ||||||
| |||||||
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. MALCOLM GOTTLICH, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. MALCOLM GOTTLICH, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).