API-c.com - Claims

Claims

What is considered a claim?
What is a notice of claim?
What is a "claims-made" policy?
What is prior acts coverage?
What is Extended Reporting Period Coverage (tail)?
What is vicarious liability?
What is a lawsuit?
What is a deposition?
What is an endorsement?
What is negligence?
Should I report a request for medical records?
Do I have to provide medical records in response to a request? If so, can I charge?
Do I have to keep treating a patient who calls after receiving a claim or lawsuit?
What is the Statute of Limitations for medical malpractice claims?
How will a claim affect my premium?
What is reported to the National Practitioner Data Bank?
What is a reservation of rights?
What do I do when I receive a subpoena for a deposition?
Do I have my choice of attorneys?
What is "Stowers"?
What are the claim reporting requirements?
What happens when a claim is reported?

Q. What is considered a claim?: A. The receipt of a summons or citation by API; the receipt by API of a written notice of claim sent pursuant to Chapter 74 of the Civil Practice and Remedies Codes, formerly Article 4590i Section 4.01 of the Texas Medical Liability and Insurance Improvement Act; or the receipt by API of a written demand from a patient or patient's representative for monetary damages.
Q. What is a notice of claim?: A. A Notice of Claim is an investigatory time period set by Chapter 74 of the Civil Practice and Remedies Code, which tolls the statute of limitations as to all potential defendants for 60 days. The intent was to allow a physician and his insurer 60 days in which to investigate and evaluate the patient's claim prior to a lawsuit being filed. The statute requires the notice to be sent by certified mail and a return receipt requested. Notice of Claim
Q. What is a "claims-made" policy?: A. A Claims-Made policy provides coverage only for claims made against professional services rendered" on or after the retroactive date of the policy. In addition, the policy only covers claims that are reported while the policy is in force. Once coverage is terminated, reporting rights cease unless extended reporting rights, commonly referred to as "tail," are purchased.
Q. What is prior acts coverage?: A. Coverage for incidents occurring prior to the effective date, but subsequent to the retroactive date.
Q. What is Extended Reporting Period Coverage (tail)?: A. Coverage that extends the time for reporting claims after a policy has been terminated or canceled; extended reporting period coverage. Many companies, such as API, provide free tail in the event of death, total disability and, with certain restrictions, retirement.
Q. What is vicarious liability?: A. Liability on your part with respect to any professional services rendered by someone else for whose conduct you are legally responsible.
Q. What is a lawsuit?: A. A lawsuit for medical malpractice is a complaint filed by a plaintiff in a court of law alleging a breach of the standard of care by one or more defendants. The Lawsuit Anatomy of a Lawsuit
Q. What is a deposition?: A. A deposition is testimony that is given under oath before a court reporter. It is very important in the preparation of a case for trial. In fact your deposition may be one of the most important steps in preparation for trial.
Q. What is an endorsement?: A. A document which changes the named insured or coverage provisions in the policy. The terms of any endorsement supersede the policy terms.
Q. What is negligence?: A. Specific to medical malpractice, negligence constitutes a breach of the standard of care exercised by a prudent physician under the same or similar circumstances.
Q. Should I report a request for medical records?: A. If you have any concerns regarding records requests, notify the Claims Department by calling 1-800-252-3628.
Q. Do I have to provide medical records in response to a request? If so, can I charge?: A. If you have received a properly executed HIPAA compliant medical authorization, then you must provide a copy of the records. A reasonable charge for copies would be appropriate.
Q. Do I have to keep treating a patient who calls after receiving a claim or lawsuit?: A. There are pros and cons to continuing to treat a patient who has presented a claim against you. We recommend you discuss the situation with Risk Management and with your defense counsel.
Q. What is the Statute of Limitations for medical malpractice claims?: A. In Texas the Statute of Limitations is two years from either the last date of treatment or the date the negligence occurred. Under Chapter 74 of the Texas Civil Practice and Remedies Code, the SOL can be extended by 75 days if the plaintiff puts you on notice of intent to sue prior to the expiration of the two years.
Q. How will a claim affect my premium?: A. The nature of the claim, the quality of medical practice in the claim, when the claim was reported, the likelihood of payment being made, and the amount paid to date, all will have an impact on the premium. Typically, there will be an adjustment, but the amount of the adjustment is directly impacted by these factors. Contact the Underwriting Department with specific concerns by calling 1-800-252-3658.
Q. What is reported to the National Practitioner Data Bank?: A. Any payment made by API or the benefit of a physician, dentist, or other health care practitioner in settlement of a claim or judgement must be reported to the Data Bank. Medical malpractice payments are limited to exchanges of money and must be the result of a written complaint or claim demanding monetary payment for damages. A practitioner may add his or her own statement to a report, or may initiate a dispute of the factual accuracy of a report or whether a report was submitted according to Data Bank requirements.
Q. What is a reservation of rights?: A. When the allegations against an insured include allegations which may be excluded under the policy, we have a duty to advise you of those exclusions in the policy and to "reserve our rights" to decline coverage based on the exclusions should there by a finding of damages associated with those allegations.
Q. What do I do when I receive a subpoena for a deposition?: A. Immediately contact the Claims Department at 1-800-252-3628. They will discuss the matter with you and if your medical care is at issue, assign an attorney to prepare you for the deposition.
Q. Do I have my choice of attorneys?: A. API has an extensive list of counsel which has been approved by our Board of Directors. Each firm has proven itself in the courtroom and we continually monitor the performance of attorneys to confirm that our physicians are being vigorously defended. Under the terms of the policy, API has the right to choose defense counsel.
Q. What is "Stowers"?: A. "Stowers" refers to a 1920's case involving the Stowers Furniture Company. A claim was brought against the company as a result of a vehicle accident. The case went to trial and there was a verdict against Stowers Furniture Co. for an amount greater than their policy limit. The Stowers Furniture Co. sued its insurance carrier for the excess damages. The court found that the insurance carrier had acted in bad faith in unnecessarily exposing its insured to excess damages since it was determined that the carrier had an opportunity to settle the claim within the policy limit and had not communicated the offer to Stowers Furniture Co.
Q. What are the claim reporting requirements?: A. If someone places you on written notice of a claim or serves you with lawsuit papers, you must immediately notify us in writing. Please refer to the API policy for further instructions.
Q. What happens when a claim is reported?

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Claims