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Department File Number : |
M200534330 |
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Claim Number : |
20181 |
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Date Submitted : |
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Insurer Information |
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Insurer Name |
Coverage Type |
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MAG MUTUAL INSURANCE COMPANY |
Primary |
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Insurer FEIN |
Professional License Number |
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58-1449198 |
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Insurer Contact Information |
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Type |
Entity Name |
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Entity |
MAG Mutual Insurance Company |
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Street Address |
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City |
State |
Zip |
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FL |
32819 |
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Phone |
Ext |
Fax |
E-Mail Address |
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(407) 370 - 3813 |
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(407) 370 - 2247 |
cwehner@magmutual.com |
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Insured Information |
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Type |
First Name |
MI |
Last Name |
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Individual |
Jeffrey |
S |
Smowton |
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Insurer Type |
Street Address of Practice |
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Licensed |
820 Prudential Drive, |
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City |
State |
Zip Code |
County |
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FL |
32207 |
Duval |
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Policy Number |
Per Claim Policy Limits |
Aggregate Policy Limits |
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PSL 1600109 03 |
$500,000 |
$1,500,000 |
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Profession or Business |
Other Profession or Business |
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Medical Doctor |
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License Number |
Specialty Code & Classification |
Certification Number |
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ME51065 |
Emergency Medicine - No Major Surgery |
01103 |
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Injured Person Information |
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First Name |
MI |
Last Name |
Date of Birth |
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Street Address |
Gender |
County where Injury Occurred |
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F |
Duval |
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City |
State |
Zip Code |
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Location where injury occured |
Other location where injury occured |
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Emergency Room |
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Name of Institution |
Code |
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BAPTIST MEDICAL CENTER - BEACHES |
100117 |
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Location of Institutional Injury |
Other Location of Institutional
Injury |
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Radiology, Emergency Room |
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Date of Occurrence |
Date Reported to Insurer |
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9/17/2003 |
11/19/2003 |
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Diagnostic Information |
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Final Diagnosis For Which Treatment
Was Sought Including Patient's Actual Condition |
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Dyspnea |
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Operation, Diagnostic, Or Treatment
Procedure Rendered Causing The Injury |
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Physical exam, lab studies, transfer
to psychiatrist |
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Diagnostic Code : |
DC1947.8 |
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Misdiagnosis Made, If Any, Of
Patient's Actual Condition |
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Alleged failure to fully evaluate,
monitor, and treat patient with premature transfer when not medically stable |
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Principal Injury Giving Rise To The
Claim |
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Death |
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Severity Of Injury |
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Permanent: Death. |
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Legal Information |
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Date of Suit |
Circuit Court Case Number |
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*NR |
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County Suit Filed in |
Date of Final Disposition |
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*NR |
2/3/2005 |
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Other Defendants Involved in this
Claim |
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Stage of Legal System at which
Settlement was Reached or Award Made |
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Within the pre-suit period as set
forth in 766.106 (more than 90 days before suit is filed). |
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Final Method of Claim Disposition |
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Settled by parties |
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Court Decision |
Other |
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No Court Proceedings. |
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Arbitration |
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Claim not subject to Arbitration. |
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Date of Payment |
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2/3/2005 |
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Financial Information |
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Was there a settlement Resulting in
payment to the Plaintiff? |
Yes |
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Indemnity Paid by Insurer on behalf
of Insured |
$50,000 |
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Loss Adjust Expense Paid to Defense
Counsel |
$0 |
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All Other Loss Adjustment Expense
Paid |
$0 |
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Injured Person's Total Non-Economic
Loss |
$0 |
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Deductible |
$50,000 |
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Injured Person's Total Economic Loss |
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Safety Management Steps Taken by
Insured to Make Similar Occurrence Less Likely |
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Risk Management has counseled insured
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Updates |
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No updates found. |