| Department File Number : | M201680280 |
| Claim Number : | 2016008252 |
| Date Submitted : | 11/16/2016 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| ALLIED WORLD SURPLUS LINES INSURANCE COMPANY | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 51-0331163 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Joyce | M | Palmisano | ||
| Street Address | |||||
| 1690 New Britain Ave. Suite 101 | |||||
| City | State | Zip | |||
| Farmington | CT | 06032 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (860) 284 - 1382 | 1382 | (860) 284 - 1383 | Joyce.Palmisano@awac.com | ||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | RAFAEL | MONTALVO RODRIGUEZ | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 11205 Running Pine Drive | ||||
| City | State | Zip Code | County | ||
| Riverview | FL | 33569 | Hillsborough | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 0307-4422 | $2,000,000 | $4,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Other | Registered Nurse | ||||
| License Number | Specialty Code & Classification | Certification Number | |||
| RN9281678 | |||||
| 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 | ||||
| Florida Hospital Wesley Chapel | 23960099 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Patients' Room | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 1/20/2014 | 4/13/2016 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Lower extremity weakness and fatigue, acute non-sustained ventricular tachycardia and shortness of breath. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Assessment and monitoring. | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| Medication error | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Failure to monitor. | |||||
| Severity Of Injury | |||||
| Permanent: Death. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| *NR | |||||
| County Suit Filed in | Date of Final Disposition | ||||
| *NR | 11/11/2016 | ||||
| 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 | |||||
| 11/11/2016 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $100,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $25,308 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $0 | ||||||||||||||||||||
| Injured Person's Total Non-Economic Loss | $100,000 | ||||||||||||||||||||
| Deductible | $0 | ||||||||||||||||||||
| Injured Person's Total Economic Loss | |||||||||||||||||||||
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| Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
| Worked closely with defense counsel to resolve claim. | |||||||||||||||||||||
| Updates | ||||||||||||||||||||||||||||||||||
| Date of Change: | 11/16/2016 4:10:14 PM | |||||||||||||||||||||||||||||||||
| Reason for Change: | At the time of my initial report, I did not know that the settlement payment was made on behalf of the Nurse, Rafael Montalvo, not the Insured Entity. This report states the settlement was made on behalf of the Nurse. | |||||||||||||||||||||||||||||||||
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*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. RAFAEL MONTALVO RODRIGUEZ, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. RAFAEL MONTALVO RODRIGUEZ, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).