| Department File Number : | M201781915 |
| Claim Number : | 1035133-02 |
| Date Submitted : | 8/28/2017 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| MEDICAL PROTECTIVE COMPANY (THE) | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 35-0506406 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Lynn | Louthan | |||
| Street Address | |||||
| 5814 Reed Road | |||||
| City | State | Zip | |||
| Ft Wayne | IN | 46835 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (260) 486 - 0778 | reportaclaim@medpro.com | ||||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Sahel | Farhangi | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 5005 Main St Ste 107 | ||||
| City | State | Zip Code | County | ||
| Tocoma | WA | 98407 | Out of state | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 785069 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Dentistry | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| DN20685 | Dental General Practice - NOC | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| F | Escambia | ||||
| 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 | ||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 7/8/2014 | 11/9/2016 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Presented for comprehensive exam | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Root Canal therapy procedure | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| failing to inform patient that an endodontic file broke during root canal therapy on tooth #4 | |||||
| Principal Injury Giving Rise To The Claim | |||||
| required extensive follow up dental treatment , pain and suffering | |||||
| 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 | 4/18/2017 | ||||
| Other Defendants Involved in this Claim | |||||
| Farrugia, DMD, Alan C | |||||
| 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 | $1,867 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $41 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| n/a | |||||||||||||||||||||
| Updates | ||||||||||
| Date of Change: | 8/23/2017 2:04:48 PM | |||||||||
| Reason for Change: | correction of patients date of birth | |||||||||
| ||||||||||
| Date of Change: | 8/28/2017 3:31:18 PM | |||||||||
| Reason for Change: | ALE UPDATE 8/28/2017 | |||||||||
| ||||||||||
*NR: Prior to 04/28/1999 this field was not required in submitted claims. This page is not displaying certain sensitive information.
Does Dr. SAHEL FARHANGI, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. SAHEL FARHANGI, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).