| Department File Number : | M201573097 |
| Claim Number : | 5149494-01 |
| Date Submitted : | 8/25/2015 |
| 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 | Susan | K | Spielman | ||
| Street Address | |||||
| 5814 Reed Road | |||||
| City | State | Zip | |||
| Fort Wayne | IN | 46835 | |||
| Phone | Ext | Fax | E-Mail Address | ||
| (260) 486 - 0340 | reportaclaim@medpro.com | ||||
| Insured Information | |||||
| Type | First Name | MI | Last Name | ||
| Individual | Zia | Fatemi | |||
| Insurer Type | Street Address of Practice | ||||
| Licensed | 758 N Sun Drive, Ste 104 | ||||
| City | State | Zip Code | County | ||
| Lake Mary | FL | 32746 | Seminole | ||
| Policy Number | Per Claim Policy Limits | Aggregate Policy Limits | |||
| 739728 | $250,000 | $750,000 | |||
| Profession or Business | Other Profession or Business | ||||
| Medical Doctor | |||||
| License Number | Specialty Code & Classification | Certification Number | |||
| ME74891 | Internal Medicine - No Surgery | ||||
| Injured Person Information | |||||
| First Name | MI | Last Name | Date of Birth | ||
| Street Address | Gender | County where Injury Occurred | |||
| F | Seminole | ||||
| 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 | ||||
| 3/8/2011 | 10/27/2011 | ||||
| Diagnostic Information | |||||
| Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition | |||||
| Crohn's Disease | |||||
| Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury | |||||
| Referral to tertiary facility | |||||
| Diagnostic Code : | |||||
| Misdiagnosis Made, If Any, Of Patient's Actual Condition | |||||
| Improper referral | |||||
| Principal Injury Giving Rise To The Claim | |||||
| Expense not covered by insurance | |||||
| Severity Of Injury | |||||
| Temporary: Minor - Infections, misset fracture, fall in hospital. Recovery delayed. | |||||
| Legal Information | |||||
| Date of Suit | Circuit Court Case Number | ||||
| 5/10/2012 | 2012-CA-2438-11 | ||||
| County Suit Filed in | Date of Final Disposition | ||||
| Seminole | 12/19/2014 | ||||
| Other Defendants Involved in this Claim | |||||
| Suncoast Medical Associates PA | |||||
| 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 | |||||
| No Payment Made | |||||
| 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 | $37,158 | ||||||||||||||||||||
| All Other Loss Adjustment Expense Paid | $4,005 | ||||||||||||||||||||
| 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: | 8/25/2015 5:09:15 PM | |||||||||
| Reason for Change: | ALE UPDATE | |||||||||
| ||||||||||
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Does Dr. ZIA FATEMI, MD have any medical malpractice cases, lawsuits, or complaints?
Dr. ZIA FATEMI, MD has at least 1 medical malpractice case(s), lawsuit(s), or complaint(s).