Department File Number : | M201575924 |
Claim Number : | HMA45054 |
Date Submitted : | 9/29/2015 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
COLUMBIA CASUALTY COMPANY | Primary | ||||
Insurer FEIN | Professional License Number | ||||
47-0490411 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Marina | Miranda | |||
Street Address | |||||
333 S Wabash Ave | |||||
City | State | Zip | |||
Chicago | IL | 60604 | |||
Phone | Ext | Fax | E-Mail Address | ||
(312) 822 - 2261 | marina.miranda@cna.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | MARK SERGIO | S | TUBEROSO | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 1516 S Nova Rd | ||||
City | State | Zip Code | County | ||
Daytona Beach | FL | 32114 | Volusia | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
SLD 4022814699 | $1,000,000 | $3,000,000 | |||
Profession or Business | Other Profession or Business | ||||
Dentistry | |||||
License Number | Specialty Code & Classification | Certification Number | |||
DN15333 | Dentists |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | Volusia | ||||
City | State | Zip Code | |||
Location where injury occured | Other location where injury occured | ||||
Other Outpatient Facility | Dental Office | ||||
Name of Institution | Code | ||||
Location of Institutional Injury | Other Location of Institutional Injury | ||||
Special Procedure Room | |||||
Date of Occurrence | Date Reported to Insurer | ||||
10/16/2014 | 4/10/2015 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Patient presented for teeth extractions. | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Insured performed teeth extractions. | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
*NR | |||||
Principal Injury Giving Rise To The Claim | |||||
Patient had trouble breathing during procedure. | |||||
Severity Of Injury | |||||
Temporary: Minor - Infections, misset fracture, fall in hospital. Recovery delayed. |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 9/15/2015 | ||||
Other Defendants Involved in this Claim | |||||
Stage of Legal System at which Settlement was Reached or Award Made | |||||
Claim or suit abandoned. | |||||
Final Method of Claim Disposition | |||||
Dropped before Action Filed | |||||
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 | $2,528 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $0 | ||||||||||||||||||||
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 | |||||||||||||||||||||
Enforcing guidelines and policies to prevent risks. |
Updates | |
No updates found. |
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Department File Number : | M201678897 |
Claim Number : | HMA60062 |
Date Submitted : | 7/1/2016 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
COLUMBIA CASUALTY COMPANY | Primary | ||||
Insurer FEIN | Professional License Number | ||||
47-0490411 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Shauna | Jumper | |||
Street Address | |||||
333 S Wabash Ave | |||||
City | State | Zip | |||
Chicago | IL | 60604 | |||
Phone | Ext | Fax | E-Mail Address | ||
(312) 822 - 5419 | Shauna.Jumper@cna.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | MARK SERGIO | S | TUBEROSO | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 3781 S Nova Road | ||||
City | State | Zip Code | County | ||
Port Orange | FL | 32129 | Volusia | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
SLD 4022814699 | $1,000,000 | $3,000,000 | |||
Profession or Business | Other Profession or Business | ||||
Dentistry | |||||
License Number | Specialty Code & Classification | Certification Number | |||
DN15333 | Dental General Practice - NOC |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | Volusia | ||||
City | State | Zip Code | |||
Location where injury occured | Other location where injury occured | ||||
Other Location | Dental Office | ||||
Name of Institution | Code | ||||
Location of Institutional Injury | Other Location of Institutional Injury | ||||
Special Procedure Room | |||||
Date of Occurrence | Date Reported to Insurer | ||||
2/26/2016 | 3/9/2016 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Pain and suffering | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Patient needed dental work performed. | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
*NR | |||||
Principal Injury Giving Rise To The Claim | |||||
Insured place a number of gold on-lays on the patient's teeth. | |||||
Severity Of Injury | |||||
Temporary: Minor - Infections, misset fracture, fall in hospital. Recovery delayed. |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 6/9/2016 | ||||
Other Defendants Involved in this Claim | |||||
Stage of Legal System at which Settlement was Reached or Award Made | |||||
Claim or suit abandoned. | |||||
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 | $742 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $0 | ||||||||||||||||||||
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 | |||||||||||||||||||||
Consult advise from Legal counsel |
Updates | |
No updates found. |
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. MARK SERGIO S TUBEROSO, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. MARK SERGIO S TUBEROSO, MD has at least 2 medical malpractice case(s), lawsuit(s), or complaint(s).