M200010665

Insurer Information

Insurer Name				Coverage Type
LEGION INSURANCE COMPANY				Primary
Insurer FEIN		Professional License Number
23-1892289
Insurer Contact Information
Type		Entity Name
Entity		PROFESSIONAL RISK MANAGEMENT SERVICES
Street Address
1515 Wilson Blvd., Suite 800
City				State	Zip
Arlington				VA	22309
Phone	Ext	Fax	E-Mail Address
(703) 907 - 3800		(703) 276 - 9419

Insured Information

Type	First Name		MI	Last Name
Individual	OFELIA			MARALIT-BORLONGAN MD
Insurer Type		Street Address of Practice
Licensed		153 Eldredge Rd
City		State	Zip Code	County
Ft. Walton		FL	32547	Walton
Policy Number		Per Claim Policy Limits		Aggregate Policy Limits
GL3000001		$1,000,000		$3,000,000
Profession or Business			Other Profession or Business
Medical Doctor
License Number		Specialty Code & Classification		Certification Number
0029674		Physciatry - Including Child		-

Injured Person Information

First Name	MI	Last Name		Date of Birth

Street Address			Gender	County where Injury Occurred
			M	*NR
City			State	Zip Code

Location where injury occured		Other location where injury occured
Patient's Home
Name of Institution		Code

Location of Institutional Injury		Other Location of Institutional Injury

Date of Occurrence		Date Reported to Insurer
9/28/1994		4/23/1996

Diagnostic Information

Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition
Heart attack
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury
Alleged failure to diagnose cardiac abnormality
Diagnostic Code :
Misdiagnosis Made, If Any, Of Patient's Actual Condition
Failure to daignose cardiac abnormality
Principal Injury Giving Rise To The Claim
Patient's death
Severity Of Injury
Permanent: Death.

Legal Information

Date of Suit	Circuit Court Case Number
	*NR
County Suit Filed in	Date of Final Disposition
*NR	11/10/1999
Other Defendants Involved in this Claim
COPE, INC WALTON REGIONAL HOSPITAL GARCIA MD, RUBEN
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

Financial Information

Was there a settlement Resulting in payment to the Plaintiff?

Yes

Indemnity Paid by Insurer on behalf of Insured

$28,125

Loss Adjust Expense Paid to Defense Counsel

$494,440

All Other Loss Adjustment Expense Paid

Injured Person's Total Non-Economic Loss

Deductible

Injured Person's Total Economic Loss

Safety Management Steps Taken by Insured to Make Similar Occurrence Less Likely

N/A

Updates

No updates found.