Department File Number :

M200012320

Claim Number :

116279

Date Submitted :

8/4/2000

 

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

Florida Office of Insurance Regulation
Medical Malpractice Closed Claims Report

 

 

 

 

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.

Florida Office of Insurance Regulation
Medical Malpractice Closed Claims Report

 

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

$0

Deductible

$0

Injured Person's Total Economic Loss

 

Incurred to Date

Anticipated

Medical Expense

$0

$0

Wage Loss

$0

$0

Other Expenses

$0

$0

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

Unknown.

 

Updates

 

No updates found.