Department File Number : | M201679448 |
Claim Number : | 1501150100855.00 |
Date Submitted : | 8/18/2016 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
PREFERRED PROFESSIONAL INSURANCE COMPANY | Primary | ||||
Insurer FEIN | Professional License Number | ||||
47-0580977 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Teri | D | Zealand | ||
Street Address | |||||
11605 Miracle HIlls Dr | |||||
City | State | Zip | |||
Omaha | NE | 68154 | |||
Phone | Ext | Fax | E-Mail Address | ||
(402) 965 - 3224 | tzealand@ppicins.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Theresa | R | Fortaleza-Dawson | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 1880 E Commercial Blvd, Ste 3 | ||||
City | State | Zip Code | County | ||
Fort Lauderdale | FL | 33308 | Broward | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
BPP0038853 | $250,000 | $750,000 | |||
Profession or Business | Other Profession or Business | ||||
Medical Doctor | |||||
License Number | Specialty Code & Classification | Certification Number | |||
ME81298 | Internal Medicine - No Surgery |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
F | Broward | ||||
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 | Dr Office | ||||
Date of Occurrence | Date Reported to Insurer | ||||
1/23/2015 | 9/23/2015 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
patient went for regular checkup | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
no treatment | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
Patient wanted CT scan but never showed for it and didn't return msgs left by dr office | |||||
Principal Injury Giving Rise To The Claim | |||||
Patient fell at dr office while having a regular checkup | |||||
Severity Of Injury | |||||
Temporary: Slight - Lacerations, contusions, minor scars, rash. No delay. |
Legal Information | |||||
Date of Suit | Circuit Court Case Number | ||||
*NR | |||||
County Suit Filed in | Date of Final Disposition | ||||
*NR | 8/17/2016 | ||||
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 | |||||
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 | $360 | ||||||||||||||||||||
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 | |||||||||||||||||||||
the office is reviewing their safe guards |
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. THERESA R FORTALEZA-DAWSON, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. THERESA R FORTALEZA-DAWSON, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).