Department File Number :	M200116076
Claim Number :	99M15774
Date Submitted :	4/25/2001

Insurer Information
Insurer Name				Coverage Type
FRONTIER INSURANCE COMPANY				Primary
Insurer FEIN		Professional License Number
13-2559805
Insurer Contact Information
Type	First Name		MI	Last Name
Individual	SHARON			LOCH
Street Address
195 Lake Louise Marie Road
City				State	Zip
Rock Hill				NY	12775
Phone	Ext	Fax	E-Mail Address
(914) 796 - 2300	5474	(914) 796 - 1801

Insured Information
Type	First Name		MI	Last Name
Individual	RUBEN			VALLEJO
Insurer Type		Street Address of Practice
Licensed		1330 SE 4TH AVENUE SUITE B
City		State	Zip Code	County
FORT LAUDERDALE		FL	33316	Broward
Policy Number		Per Claim Policy Limits		Aggregate Policy Limits
ML0302523		$250,000		$750,000
Profession or Business			Other Profession or Business
Medical Doctor
License Number		Specialty Code & Classification		Certification Number
32290FL		Internal Medicine - Minor Surgery		80284

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
			F	*NR
City			State	Zip Code
Location where injury occured		Other location where injury occured
Hospital Outpatient Facility
Name of Institution		Code
NORTH BROWARD MEDICAL CENTER		100086
Location of Institutional Injury		Other Location of Institutional Injury
Patients' Room
Date of Occurrence		Date Reported to Insurer
2/16/1999		2/19/1999

Diagnostic Information
Final Diagnosis For Which Treatment Was Sought Including Patient's Actual Condition
attempted suicide
Operation, Diagnostic, Or Treatment Procedure Rendered Causing The Injury
failure to monitor patient
Diagnostic Code :	789.4
Misdiagnosis Made, If Any, Of Patient's Actual Condition
*NR
Principal Injury Giving Rise To The Claim
patient committed suicide
Severity Of Injury
Permanent: Death.

Florida Office of Insurance Regulation
Medical Malpractice Closed Claims Report

Legal Information
Date of Suit	Circuit Court Case Number
	*NR
County Suit Filed in	Date of Final Disposition
*NR	6/28/2000
Other Defendants Involved in this Claim
Stage of Legal System at which Settlement was Reached or Award Made
Within the pre-suit period as set forth in 766.106 (more than 90 days before suit is filed).
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

$162,500

Loss Adjust Expense Paid to Defense Counsel

$1,556

All Other Loss Adjustment Expense Paid

$1,080

Injured Person's Total Non-Economic Loss

$162,500

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

The insured has consulted with defense counsel, medical experts, and claims personnel regarding this matter.

Updates

No updates found.