M200012320

Insurer Information

Insurer Name				Coverage Type
DOCTORS' COMPANY, AN INTERINSURANCE EXCHANGE (THE)				Primary
Insurer FEIN		Professional License Number
95-3014772
Insurer Contact Information
Type	First Name		MI	Last Name
Individual	STACY		L	FIALKOWSKI
Street Address
5100 N.W. 33rd Avenue, Suite 251
City				State	Zip
Fort Lauderdale				FL	33309
Phone	Ext	Fax	E-Mail Address
(954) 714 - 5111		(954) 735 - 5446	sfialkowski@thedoctors.com

Insured Information

Type	First Name		MI	Last Name
Individual	ARIE			DEN BREEIJEN
Insurer Type		Street Address of Practice
Licensed		1417 LAKELAND HILLS BLVD., SUITE 203
City		State	Zip Code	County
LAKELAND		FL	33805	Polk
Policy Number		Per Claim Policy Limits		Aggregate Policy Limits
15040		$1,000,000		$3,000,000
Profession or Business			Other Profession or Business
Medical Doctor
License Number		Specialty Code & Classification		Certification Number
ME0010918				00000

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
2/14/1997		5/18/1998

Diagnostic Information

Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition
Major depression with suicidal ideation.
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury
None
Diagnostic Code :
Misdiagnosis Made, If Any, Of Patient's Actual Condition
None
Principal Injury Giving Rise To The Claim
Death by suicide - a gunshot wound to the head.
Severity Of Injury
Permanent: Death.

Legal Information

Date of Suit	Circuit Court Case Number
10/28/1998	G 98-2782
County Suit Filed in	Date of Final Disposition
Polk	6/9/2000
Other Defendants Involved in this Claim
LAKELAND COUNSELING SERVICES SULLIVAN, LCSW, ELLEN J
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

$90,000

Loss Adjust Expense Paid to Defense Counsel

$46,115

All Other Loss Adjustment Expense Paid

$11,029

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

Unknown.

Updates

No updates found.