| Department File Number : | M201575654 |
| Claim Number : | FP4348201 |
| Date Submitted : | 8/26/2015 |
| Insurer Information | |||||
| Insurer Name | Coverage Type | ||||
| FIRST PROFESSIONALS INSURANCE COMPANY, INC | Primary | ||||
| Insurer FEIN | Professional License Number | ||||
| 59-6614702 | |||||
| Insurer Contact Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Kelly | Andrews | |||
| Street Address | |||||
| 12724 Gran Bay Parkway W., Suite 400 | |||||
| City | State | Zip | |||
| Jacksonville | FL | 32258 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (904) 360 - 3038 | kandrews@thedoctors.com | ||||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Shari | B | Goldstein | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 16059 Rosecraft Terrace | ||||
| City | State | Zip Code | County | ||
| Delray Beach | FL | 33446 | Palm Beach | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| FP-IN104010 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Dentistry | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| DN16170 | Periodontics | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| F | Palm Beach | ||||
| 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 | ||||
| Other | Dentist Office | ||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 4/1/2012 | 8/29/2012 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Implants on teeth #'s 18 & 19. | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Patient alleged failure to properly place implants on teeth #'s 18 and 19 resulting in infection and removal of implants. | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| *NR | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Removal of implants and infection. | |||||
| Severity Of Injury | |||||
| Temporary: Minor - Infections, misset fracture, fall in hospital. Recovery delayed. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 4/30/2014 | 14-004071 CA | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Palm Beach | 8/19/2015 | ||||
| Other Defendants Involved in this Claim | |||||
| Ferber, Brian Ferber Dental Group | |||||
| 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 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $24,900 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $17,800 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $6,208 | ||||||||||||||||||||
| 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 | |||||||||||||||||||||
| Insurance company staff consulted with insured to discuss preventative measures. Patient Safety referral is made if appropriate. | |||||||||||||||||||||
| 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. SHARI B GOLDSTEIN, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. SHARI B GOLDSTEIN, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).