Department File Number : | M201886679 |
Claim Number : | 2017-124447 |
Date Submitted : | 10/11/2018 |
Insurer Information | |||||
Insurer Name | Coverage Type | ||||
NATIONAL UNION FIRE INSURANCE CO. OF PITTSBURGH, PA | Primary | ||||
Insurer FEIN | Professional License Number | ||||
25-0687550 | |||||
Insurer Contact Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Connie | L | Peters | ||
Street Address | |||||
PO Box 52810 | |||||
City | State | Zip | |||
Bellevue | WA | 98015 | |||
Phone | Ext | Fax | E-Mail Address | ||
(425) 636 - 1000 | 1012 | (916) 781 - 5795 | cpeters@intercareins.com |
Insured Information | |||||
Type | First Name | MI | Last Name | ||
Individual | Vernon | S | Smith | ||
Insurer Type | Street Address of Practice | ||||
Licensed | 4145 US Highway 98 N | ||||
City | State | Zip Code | County | ||
Lakeland | FL | 33809 | Polk | ||
Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
DNU064842263 | $500,000 | $1,500,000 | |||
Profession or Business | Other Profession or Business | ||||
Dentistry | |||||
License Number | Specialty Code & Classification | Certification Number | |||
DN19861 | Dental General Practice - NOC | 80211 |
Injured Person Information | |||||
First Name | MI | Last Name | Date of Birth | ||
Street Address | Gender | County where Injury Occurred | |||
M | Polk | ||||
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 | Dental treatment rom | ||||
Date of Occurrence | Date Reported to Insurer | ||||
6/21/2017 | 7/14/2017 |
Diagnostic Information | |||||
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
Need for restorative treatment; including fillings | |||||
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
Fillings were placed | |||||
Diagnostic Code : | |||||
Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
No misdiagnosis | |||||
Principal Injury Giving Rise To The Claim | |||||
Alleged failure of polishing burr. | |||||
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 | 9/18/2018 | ||||
Other Defendants Involved in this Claim | |||||
Stage of Legal System at which Settlement was Reached or Award Made | |||||
Settlement Reached Prior to Pre-Suit Period | |||||
Final Method of Claim Disposition | |||||
Settled by parties | |||||
Court Decision | Other | ||||
No Court Proceedings. | |||||
Arbitration | |||||
Claim not subject to Arbitration. | |||||
Date of Payment | |||||
9/18/2018 |
Financial Information | |||||||||||||||||||||
Was there a settlement Resulting in payment to the Plaintiff? | Yes | ||||||||||||||||||||
Indemnity Paid by Insurer on behalf of Insured | $20,000 | ||||||||||||||||||||
Loss Adjust Expense Paid to Defense Counsel | $0 | ||||||||||||||||||||
All Other Loss Adjustment Expense Paid | $575 | ||||||||||||||||||||
Injured Person's Total Non-Economic Loss | $14,731 | ||||||||||||||||||||
Deductible | $0 | ||||||||||||||||||||
Injured Person's Total Economic Loss | |||||||||||||||||||||
| |||||||||||||||||||||
Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely | |||||||||||||||||||||
No safety management steps taken. |
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. VERNON S SMITH, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. VERNON S SMITH, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).