| Department File Number : | M201887437 |
| Claim Number : | 69031 |
| Date Submitted : | 12/26/2018 |
| 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 | Matthew | H | Berlet | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 4516 N Armenia Ave | ||||
| City | State | Zip Code | County | ||
| Tampa | FL | 33603 | Hillsborough | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| PSL 1602053 14 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME63918 | Radiology - Diagnostic - Minor Surgery | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Hillsborough | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Hospital Inpatient Facility | |||||
| Name of Institution | Code | ||||
| SAINT JOSEPH'S HOSPITAL | 100075 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Operating Suite | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 1/31/2017 | 6/1/2018 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Fractured vertebrae | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Vertebroplasty | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| Alleged failure to properly perform procedure | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Wrong level procedure requiring additional vertebroplasty | |||||
| Severity Of Injury | |||||
| Temporary: Major - Burns, surgical material left, drug side effect, brain damage. Recovery delayed. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| *NR | |||||
| County Suit Filed in | Date of Final Disposition | ||||
| *NR | 11/28/2018 | ||||
| Other Defendants Involved in this Claim | |||||
| Stage of Legal System at which Settlement was Reached or Award Made | |||||
| Within the pre-suit period as set forth in 766.106 (more than 90 days before suit is filed). | |||||
| Final Method of Claim Disposition | |||||
| Settled by parties | |||||
| Court Decision | Other | ||||
| No Court Proceedings. | |||||
| Arbitration | |||||
| Claim not subject to Arbitration. | |||||
| Date of Payment | |||||
| 11/28/2018 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $99,999 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $5,410 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $3,874 | ||||||||||||||||||||
| 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. |
| Department File Number : | M201884348 |
| Claim Number : | 60204 |
| Date Submitted : | 3/23/2018 |
| 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 | Matthew | H | Berlet | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 4516 N. Armenia Ave. | ||||
| City | State | Zip Code | County | ||
| Tampa | FL | 33603 | Hillsborough | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| PSL 1602053 12 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME63918 | Radiology - Diagnostic - Minor Surgery | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| F | Hillsborough | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Hospital Inpatient Facility | |||||
| Name of Institution | Code | ||||
| ST JOSEPHS HOSPITAL NORTH | 23960100 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Operating Suite | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 6/28/2016 | 12/5/2016 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Aneurysm at bifurcation of left carotid artery | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Angiography | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| Alleged improper performance of angiography including improper deployment of angio-seal closure | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Occlusion of right femoral artery | |||||
| Severity Of Injury | |||||
| Temporary: Major - Burns, surgical material left, drug side effect, brain damage. Recovery delayed. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 4/3/2017 | 17-CA-003055 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Hillsborough | 2/27/2018 | ||||
| Other Defendants Involved in this Claim | |||||
| Stern Drake Isbell & Assoc | |||||
| 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 | |||||
| 1/29/2018 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $50,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $12,391 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $7,136 | ||||||||||||||||||||
| 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 | |||||||
| Date of Change: | 3/23/2018 1:01:37 PM | ||||||
| Reason for Change: | Report updated to reflect Court Document final disposition date of 02/27/18 | ||||||
| |||||||
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Does Dr. MATTHEW H BERLET, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. MATTHEW H BERLET, MD has at least 2 medical malpractice case(s), lawsuit(s), or complaint(s).