| Department File Number : | M201884031 |
| Claim Number : | 1024705-01 |
| Date Submitted : | 8/22/2018 |
| 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 | Thomas | K | Ceballos | ||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 100 Mercy Way | ||||
| City | State | Zip Code | County | ||
| Joplin | MO | 64804 | Out of state | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 727230 | $1,000,000 | $3,000,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME92981 | Radiology - Diagnostic - Minor Surgery | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| M | Citrus | ||||
| City | State | Zip Code | |||
| Location where injury occured | Other location where injury occured | ||||
| Emergency Room | |||||
| Name of Institution | Code | ||||
| CITRUS MEMORIAL HOSPITAL | 100023 | ||||
| Location of Institutional Injury | Other Location of Institutional Injury | ||||
| Radiology, Emergency Room | |||||
| Date of Occurrence | Date Reported to Insurer | ||||
| 10/14/2011 | 3/11/2015 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Pulmonary embolus, shortness of breath | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Interpreted chest x-ray and chest CT scan | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| Failure to detect and report a potential mass in upper lobe of right lung | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Lung cancer, death | |||||
| Severity Of Injury | |||||
| Permanent: Death. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 8/14/2015 | 2015 CA 000706 A | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Citrus | 1/2/2018 | ||||
| Other Defendants Involved in this Claim | |||||
| Citrus Memorial Health Foundation Inc dba Citrus Mem Hospita Shah MD, Vikram Monojkumar B Shukla MD PA dba Citrus Pulmonary Consultants & Associated Radiologists of Inverness PA Foundation Resolution Corporation Inc HCA West Florida | |||||
| 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 | |||||
| 12/27/2017 | |||||
| Financial Information | |||||||||||||||||||||
| Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
| Indemnity Paid by Insurer on behalf of Insured | $300,000 | ||||||||||||||||||||
| Loss Adjust Expense Paid to Defense Counsel | $28,940 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $21,022 | ||||||||||||||||||||
| 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: | 8/22/2018 2:05:20 PM | |||||||||
| Reason for Change: | ALE UPDATE | |||||||||
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Does Dr. THOMAS K CEBALLOS, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. THOMAS K CEBALLOS, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).