COMPARISON OF THE NHS LITIGATION AUTHORITY AND THE COMMERCIAL INSURANCE MARKET: BRIEFING PAPER

Transcription

1 COMPARISON OF THE NHS LITIGATION AUTHORITY AND THE COMMERCIAL INSURANCE MARKET: BRIEFING PAPER

2 ff Introduction... 3 ff Key differences between CNST and commercial insurance... 5 ff Factors for consideration ff Transitional costs of leaving CNST ff Key filters ff Conclusions and recommendations Comparison of the NHS Litigation Authority and the Commercial Insurance Market

3 1 Introduction In February 2011 Marsh was appointed by the Department of Health to conduct an industry review of the NHS Litigation Authority (NHS LA). The objective of the review was to identify opportunities to introduce greater commercial management and practice to improve the efficiency of the services. In January 2012, the Department of Health (DH) published Marsh s report and agreed to consider the majority of the recommendations made. The aim of this briefing paper is to combine knowledge of the NHS LA and the commercial insurance market, to highlight key differences and areas for analysis for any Foundation Trust considering leaving the NHS LA or examining alternatives. The focus of this paper is the Clinical Negligence Scheme for Trusts (CNST) which represents the largest exposure for most Trusts 1. Until the creation of NHS Foundation Trusts, NHS Trusts were prohibited from obtaining clinical negligence insurance from the commercial insurance market, and as at 31 March 2012, no Trust had left the CNST 2. Foundation Trusts have the option of using the commercial insurance market as an alternative to the NHS LA, and they have an obligation to ensure that financial decisions are sound and offer value for money. This has therefore led to greater financial scrutiny of contributions to the NHS LA and consideration of viable alternatives. It is worth noting that the Health and Social Care Act 2012 will lead to changes in the provision of healthcare services and this will have implications for clinical negligence insurance cover. Currently, independent sector providers are not able to be members of the CNST in their own right, although DH is currently exploring how this should change. Presently the independent sector is covered for much of its provision to NHS patients through back to back indemnities with Primary Care Trusts (PCTs). At this stage, the detailed implications of the Act in terms of clinical negligence insurance cover are still uncertain and therefore not analysed within this paper. The specific exposures, claims history, costs and requirements of each healthcare provider are different and this paper does not provide definitive conclusions on the relative merits of commercial insurance versus the CNST 3. It highlights the key areas for consideration and further analysis to facilitate decision-making 4. The decision-making criteria are not straightforward, and include financial and more qualitative factors. We would be delighted to discuss further any areas of this paper, or the specific factors affecting your Trust. 1 The NHS LA also provides protection within two further schemes (Property Expenses Scheme and Liability to Third Parties Scheme); the commercial insurance market can also provide alternative protection to these schemes. 2 All Trusts are currently members. One member has indicated their intention to leave from April 2013, however, they have not at this stage, appointed an alternative provider. 3 There is a third source of potential indemnity from clinical negligence claims through the Medical Defence Organisations (MDOs), such as the Medical Defence Union (MDU), the Medical Protection Society (MPS) and the Medical and Dental Defence Union of Scotland (MDDUS). These are member organisations offering discretionary protection, although some also have the backing of an insurance policy. Overall, the MDOs offer the largest proportion of cover for the Primary Care sector, whilst the CNST and the commercial insurance market do not, generally speaking, cover this exposure. For this reason we have not provided further comparison with the protection offered by the MDOs within this paper. 4 The comments are based on the current approach of the CNST and the commercial insurance market; both of these may change as the insurance market will often be flexible to requirements, whilst the NHS LA is currently reviewing certain policies and mechanisms. Marsh 3

4 4 Comparison of the NHS Litigation Authority and the Commercial Insurance Market

5 2 Key differences between CNST and commercial insurance The CNST has been providing protection for clinical negligence to NHS Trusts in England since The commercial insurance market has been offering clinical negligence cover, outside of the NHS, for many years. The commercial market currently provides insurance cover for many private healthcare organisations within the UK and coverage for other territories. Therefore, both have significant experience of providing protection in respect of clinical negligence and an understanding of the issues involved within their respective sectors. As the commercial insurance market provides cover for territories other than England, and for the risk profile of the independent sector, this may lead to a different range of expertise than that provided by the NHS LA. It is worth noting that many insurers may offer flexibility over coverage and the structure of an insurance policy to match the needs of the policy holder, with the premium being calculated accordingly. The table overleaf refers to typical market practice, however insurers may be willing to offer alternatives. CNST Insurance market Implications and considerations Scheme type Claims Paid Claims are paid according to whether the Trust is a member when the incident occurred and when the claim is paid. The annual contributions collected are based on the claims expected to be paid within the next 12 months. This takes into account risk profiling for the NHS overall, in addition to the specific risk profile for the individual Trust. If the member leaves the scheme, any unpaid claims will no longer be paid by the scheme and will be retained by the Trust as a liability. Discretionary Duty to pay claims is discretionary. Pooling basis The scheme is a non-profit making pooling arrangement whereby the contributions are collected from members to fund losses. Claims Made The claim will be covered (subject to policy conditions) if the claim (or circumstances leading to a claim) are notified and reported during the policy duration, irrespective of when the claim is finally settled (usually subject to a retroactive date). The insurance premiums are charged based on the forecast of claims to be reported within the next 12 months, taking into account investment income which can be earned due to the delay between reporting and settlement. If a Trust leaves a commercial policy to re-enter the CNST, unreported claims at the time the policy expires are unlikely to be covered by the insurance policy without special arrangements, although the Secretary of State does have the discretion to cover them under CNST. Contractual Duty to pay claims which fall within the scope of the cover is contractual. Commercial basis The premiums are collected to be sufficient to pay losses and to generate a return on insurers capital. If the basis of cover is consistent, then there is no gap in cover. If the basis of protection changes, then there is the potential for some claims not to be reimbursed (this applies if leaving the CNST and also if subsequently leaving the commercial market to re-enter the CNST). If leaving the CNST to purchase a commercial claims made policy, then claims which have been reported but not paid by the CNST become the liability of the Trust and will not be covered by the insurance policy 5. This can have significant implications for Trusts as any outstanding claims will need to be accounted for on the balance sheet. A legal and actuarial review of any liabilities and a review of each claims circumstances should be completed before leaving any scheme to ensure that the Trust is aware of the full exposure. There is also the expense of paying the NHS LA the financial cost of any Periodical Payment Orders (PPO s) 6 if leaving the CNST. This will be a capitalised sum representing the value of the income stream which the NHS LA is committed to pay for the duration of the life of a claimant and is likely to be significant. 5 For the obligations assumed from the CNST, it may be possible to transfer these to the insurance market, but it may be difficult to obtain these at economic terms. 6 Periodical payment order is where a claim is settled either fully or partially by an agreement to pay agreed amounts at regular intervals for the remainder of the injured person s life. Marsh 5

6 6 Comparison of the NHS Litigation Authority and the Commercial Insurance Market

7 CNST Insurance market Implications and considerations Coverage Financial limits There are no financial limitations within the pooling arrangements in respect of the maximum claim amounts to be paid. If an individual has a meritorious claim against a member of the CNST, the scheme can respond with the full value of the claim (including legal fees) being paid in full by the CNST and with an unlimited financial value. Policies will have a financial limit, whereby the cost of claims in excess of the limit will not be paid by insurers and will become the liability of the Trust. For insurance, Trusts need to ensure the individual and aggregate limits are sufficient to pay for all claims which may be reported during the policy duration. In cases where the injured patient requires care for life, the capitalised value of an individual settlement can exceed 10m (significantly more if purchase of an annuity is required). There is often a significant delay in settling the claim and therefore limits need to be sufficient at the time the claim is settled. Higher limits will have higher costs. Deductible The loss is paid in full by CNST. Deductibles or excess levels usually apply whereby the first portion of any claim is paid by the Trust. The value of the deductible or excess needs to be taken into account when assessing value for money. Cashflow implications need to be assessed as does the cost of any resource required to manage the claim in-house and the volumes of claims likely to fall within the deductible/excess. The costs of deductibles can vary significantly depending on the frequency of losses. The Trust has control over the limits and the deductibles it chooses, subject to market availability and can therefore control purchasing decision. However, this also increases the uncertainty of the cost to the Trust in respect of paying the claims within the deductible. Dependent on the level of the deductible, some Trusts may be paying a significant overall value of claims (sometimes all claims) themselves without a recovery from the insurance. This is effectively self-insurance. Clinical coverage There is no limitation on the clinical specialities covered, nor on the types of clinical practice. Insurers can limit the clinical specialities covered, and may limit the types of work covered. Individual policy wordings must be fully checked to ensure complete coverage. There will often be limitations, e.g. sexual abuse claims. Exclusions There are no exclusions on the policy, if the claim is meritorious. Insurers may deny indemnity due to noncompliance with policy conditions (e.g. reporting timeframes, which may cover incidents as well as notified claims). The NHS LA historically has been more generous in dealing with protocol breaches. This may lead to increased costs within the scheme. However, where insurers may deny a claim because policy conditions are not complied with, the individual Trust will still be responsible for paying the affected patient, but without the right of recovery from insurers. Therefore, whilst the insurance policy may have a lower cost through a strict approach to denying payment where breaches of policy occur, the claims will still need to be paid by the local Trust and hence there may not be savings overall. If purchasing a commercial insurance policy, Trusts must ensure they comply with all policy conditions which may include reporting any incident which has the potential to become a claim. 7 Comparison of the NHS Litigation Authority and the Commercial Insurance Market Marsh 7

8 8 Comparison of the NHS Litigation Authority and the Commercial Insurance Market

9 CNST Insurance market Implications and considerations COSTS Premium/ contribution Costs are based on claims costs for the forthcoming year (including legal costs) of all members, plus a cost for the services of the NHS LA. Therefore, members pay a proportion (based on the Trust s own risk profile) of the scheme s global expenditure. Premium based on the Trust s risk profile, including expected claims costs and potential for larger claims. Premiums include administration costs, profit for the insurer and the cost of capital. Insurers can achieve a rate of investment income on the premiums collected due to the time delay before claim settlement. The largest cost of contributions and premiums is the expected cost of claims. If insurers can settle claims for a lower overall value than the NHS LA, then premium costs may be lower (stronger claims defensibility, settling claims quicker, potentially lower legal fees). In other fields of risk, insurers have demonstrated the ability to reduce claims costs. However, there is no historical evidence in respect of clinical negligence claims. There is an inevitable trade-off in such cases. Settling a claim more quickly to limit legal costs may have the consequence of increased damages payments and/or payment of unmeritorious claims. Equally, the robust defence of claims to reduce damages may increase legal costs and delay the settlement of meritorious claims. Investment income on premiums can be significant due to the time delay between collecting premium and paying claims. Although in the current low investment return environment this may not be significant. Profit and capital charges may offset this. If a PPO is awarded, courts require reasonable security. The NHS LA has been deemed as having this security, however, Foundation Trusts, due to the potential to become insolvent, may not be deemed secure. In this case courts may order an annuity to be purchased, which may be difficult to purchase and at very high costs. As a secure body, there is no cost implication to the NHS LA of providing security to PPOs on behalf of members whilst they remain a member. Other costs There are no deductibles or claims handling costs these costs are effectively included within the total contribution. Additional costs of losses within the deductible, claims handling and broking fees also need to be taken into account. A full appraisal is needed to compare all costs. Rebates Contribution rebates can be made (as in 2006/07) and technically additional contributions can be collected. Rebates of up to 30% are available for trusts reaching specified levels of the NHS LA s risk management assessment process. Insurers may offer partial premium rebates if risk management criteria are met. There is no right to recover additional premium mid-year if claims costs are higher than expected, although premiums may be revised to take account of this in subsequent years. A full appraisal is needed to compare all costs. Tax No insurance premium tax is payable as membership is via contributions 7. Insurance premium tax (currently 6%) is charged on any insurance policy. This additional cost (6% of premium) needs to be taken into account if considering an insurance policy. Stability of cost Annual contributions change based on the risk profile of all members; changes to allocation mechanisms may affect contributions 8. If a Trust s claims deteriorate, there is a smoothing effect amongst members; for a Trust with improving claims, the full benefit of this may not be seen in the contributions 9. Premiums will change annually. Although fixed-term deals can be achieved, these may be variable mid-term if the risk profile of the Trust changes, e.g. there is a series of claims. Premiums can also be affected by changes in the insurance market cycle, therefore, as the insurance market hardens costs may increase. Insurers may leave the market as it is no longer deemed to be sufficiently profitable. This will have an impact on stability, continuity and the availability of affordable cover. Stability of premiums and contribution costs needs to be considered. If available, stable premiums, at a fixed level for up to three years could be desirable for budgeting purposes. However, this is not standard market practice, and any subjectivities and break clauses should be checked. 7 The tax revenue would flow back to the government, however, it would have a direct cost to the Trust. 8 The CNST does have a claims experience factor which can penalise or incentivise Trusts according to claims history. However, at the time of the review, only a small number of Trusts received any adjustment. This mechanism may be changed, however, to give greater incentives. 9 Claims which arise from incidents prior to 1995, when the CNST was established are covered by the NHS LA within a scheme, separate to the CNST, which is funded centrally by the Department of Health. Marsh 9

10 CNST Insurance market Implications and considerations Incidents Prior incidents are covered, as long as the incident occurred and the claim is paid during membership. Claims arising after the policy inception and from circumstances which the Insured knew (or should have known) at the time of the policy inception may give rise to a claim, are excluded. Clarity must be sought on exactly which incidents will be excluded from a commercial policy, as Trusts have a duty to report many incidents (e.g. near misses, incidents previously reported to the National Patient Safety Agency (NPSA), now reported to Care Quality Commission (CQC). There can be significant delays between incidents and claims being reported and only a small percentage of incidents actually turn into claims. Trusts will be required to notify insurers of any claims and any circumstances which may give rise to a claim in the future. This may include, for example, where a patient has requested medical records or potentially, any adverse incident. If members leave the CNST and subsequently rejoin the scheme, incidents which occurred when not a member will not be covered by either the insurance policy or the CNST, meaning that the Trust will be financially responsible. Gaps in cover become increasingly likely if the insurance market hardens with the potential for insurers to withdraw from the business. This exposure could be very significant if an incident occurs leaving a patient with long-term care requirements (potentially 10m +). There is a potential gap in cover if moving between insurers with different reporting requirements in respect of incidents and circumstances which may give rise to a claim. With the commercial insurance market, there is an increased responsibility to ensure compliance with reporting requirements for incidents and circumstances which may give rise to a claim. Claims Handling All claims are handled by the NHS LA. As part of the NHS, the NHS LA team work with claims handlers within Trusts. The NHS LA has a highly experienced Technical Claims Unit which coordinates issues which are occurring NHS-wide to ensure that these are dealt with in a consistent and economic way. This includes identifying cases which are likely to set a precedent for the NHS and result in claims in future years. Insurers will agree the level at which they will require notification of claims, and agree the process for conduct and control of all claims (above and below the deductible). There is often the potential to buy additional claims handling resource if required, although this may not be NHS specific. Under an insurance policy, resource must be available to manage claims, either by Trust personnel or via an outsourced function. The level of resource required will depend on the frequency of claims, and incidents, and the service level agreed with insurers. This allows a level of control and influence at a local level to settle or defend claims, however, the benefits of a pool of expertise and correlation with similar claims across the NHS may be lost. Where one or more trust is involved in a claim, the insurer may require that court proceedings be pursued between them. This will increase legal costs, may affect working relationships adversely and/or attract adverse publicity. There may be reputational issues if insurers deny a claim due to policy conditions rather than the merits of a claim, although the Trust is still responsible for settling the claim, leading to financial consequences. The Trust will still have to pay for the claim, but insurers may refuse to indemnify the Trust if conditions are not complied with. Following notification of a claim to a Trust, further delays in reporting the circumstances to the CNST or the Insurer may lead to increased claims costs. The NHS LA, generally, is unlikely to refuse indemnity based on reporting delays, whilst a commercial insurer may refuse indemnity under the terms of the contract. This may increase total claims costs for the CNST with an impact for all members. However, if an insurer denies a claim due to reporting delays, this will have financial consequences for the Trust involved, as they will still have to pay the claimant, without a recovery from insurers. 10 Comparison of the NHS Litigation Authority and the Commercial Insurance Market

11 CNST Insurance market Implications and considerations Claims defensibility Conduct of patient claims is handled by the NHS LA. Trusts may have greater control of managing claims, although insurers will take a strong interest and may influence control. The insurer s claims handlers may settle claims without reference to the client. Insurers have a right to take over control of the claim at any time, including claims within the deductible. Local control may lead to more appropriate decision making, although appropriate specialist resource will be required and the pooled NHS experience will be lost. By defending more claims, or paying meritorious claims more quickly, local decision making may lead to lower costs overall. However, local expertise and adequacy of resource would be required to ensure that costs don t increase with prolonged claims. It is possible that damages may increase if unmeritorious claims are settled in the interests of reducing legal costs. The CNST team manages a large number of claims, often with similar details and therefore has the benefit of pooled experience. Insurers may have experience in clinical negligence claims, although this will not be the experience of the NHS and so will concern different risk areas and different specialities. If each claim is managed locally, the benefits of a pool of expertise may be lost. The legal firms on the specialist panel managed by the NHS LA are currently used by insurers in non-nhs clinical negligence cases. Financial security The NHS LA is a Special Health Authority, and therefore has the support of the Department of Health and ultimately of the UK government. Claims settled by PPO have the financial security of the government: satisfies court as to financial stability. Insurers will generally have a wide portfolio of risks, and their financial strength will be affected by economic conditions and their risk portfolio. Where courts are settling claims by a PPO, they will wish to satisfy themselves that the arrangements in place for payment of the annual stream of income are financially secure. Whilst the NHS LA is able to self-fund these arrangements, insurers will need to seek a commercial solution. This may be the purchase of an annuity. There is a limited market for annuities for impaired individuals and therefore the costs of insurance may be significantly higher than those for the NHS LA. If purchasing an insurance policy, the financial strength of the insurer should be checked and monitored. If an insurer is not deemed by the courts to offer appropriate financial security, then the courts may require the purchase of an annuity which has an increased cost. There can be significant delay between reporting and settling a claim, and therefore evidence of the long-term financial security of the insurer is required. Marsh 11

12 3 Factors for consideration Every Foundation Trust has an obligation to ensure that any expenditure is appropriate and represents value for money. Therefore, it is appropriate that Trusts analyse the contributions made to the CNST (and other NHS LA schemes), and compare these costs with other available alternatives. However, any comparisons should not be based purely on the cost comparison, as the protection offered differs significantly, as highlighted above. The costs of leaving the scheme also need to be taken into account. In summary, the areas which need to be considered when purchasing an insurance contract are: Financial costs Costs within deductibles/excesses and the uncertainty of these costs. Insurers will usually give control and a flexibility to choose, linked with an adjustment to the premium. Stability of costs if available, fixed premiums can be useful, although this is not normal market practice and premiums after expiry of fixed term will be uncertain. Even when fixed, premiums may change if the Trust s risk profile changes. Insurance premium tax, currently 6%, is levied on all insurance premiums. Broking fees, if applicable. Premiums can be cheaper as insurers may be able to settle claims more efficiently, however, this will depend on the claims defensibility and there will be an inevitable trade-off between speed, costs and damages. The scope to reduce expenditure overall is not proven for clinical negligence claims. The insurance market has not been involved in settling NHS claims since the CNST was established and therefore settlement rates cannot be established. Insurers will charge for profit margin and for the cost of capital. Costs of current known claims, which will be retained by the Trust as a liability and the cost of known PPOs where the cash value will need to be paid to the NHS LA on leaving the scheme. Coverage issues Financial limits, both aggregate (per period) and individual (per claim) the cost of claims above the limit, versus purchasing an excessive limit, bearing in mind that catastrophic claims can exceed 10m in value. Ensure complete cover for clinical specialties, all practitioners and all types of medical care. Incidents previously known: must check policy definition to ensure meritorious claims will not be denied, or this could lead to significant financial exposure. Administration resource and costs Cost of claims handling. Policy checking and negotiation. Other Ensure compliance with all policy conditions (e.g. claims reporting). 12 months notice of intention to leave CNST is officially required. Subrogation rights and waivers. For example, some insurers may require doctors to purchase their own indemnity insurance whilst working within the NHS. This may have implications in respect of workforce management. 12 Comparison of the NHS Litigation Authority and the Commercial Insurance Market

13 Transitional costs of leaving CNST In addition to the above comparison of costs and protection, Trusts also need to take into account the costs of leaving the CNST. Insurers may assist with these costs, for example, by offering additional insurance cover in respect of known, reported, but not settled claims. However, the additional costs of this need to be incorporated within the overall decision-making criteria. Any outstanding claims, not paid within 30 days of leaving, will become the responsibility of the Trust. This has implications on the finances and also on resource in terms of managing the claims 10 as the value of these claims will become a liability to the Trust and will need to be accounted for accordingly. The costs may be more or less than the current reserved position of the CNST. If there are any outstanding PPOs, then the cash actuarial surrender value of these has to be paid by the Trust to the NHS LA on leaving 11. Incidents previously reported: these may be denied by insurers (depending on the policy wording) and therefore appropriate funding may be required within the Trust for such occurrences. Known claims will not be covered by insurers within a standard policy, however, the issue in respect of incidents is currently unclarified. It is strongly recommended that a full financial and actuarial review of claims and claims circumstances is conducted before any decisions are taken to leave the CNST. This will allow the Trust to fully identify the potential costs involved. Key filters The circumstances for each individual Trust will vary significantly and there is no definitive answer as to which Trusts (if any) should consider alternative arrangements. However, in terms of key filters, it is likely that Trusts with the following factors, will be least likely to find viable commercial alternatives: Large value of outstanding claims (as there will be a high impact on finances on leaving the scheme). Significant value of PPOs (due to need to find financing arrangements on leaving the scheme). Trusts with a large number of incidents formally reported, which have not currently been reported (this is subject to clarification of the incidents which the commercial market will not cover). A large claims history and higher risk areas (e.g. maternity) which are likely to make viable commercial alternatives harder to obtain. The Trusts for whom there is greater potential for commercial alternatives, are more likely to: Be seeking greater control over levels of risk transfer, e.g. if Trusts wish to have a choice over deductible/excess levels. This will have resource and cost implications. Believe their claims can be settled for lower costs through a combination of the Trust and insurer expertise. Have fewer legacy risks (e.g. outstanding claims, PPOs). Have effective risk management in place. Be able to secure commercial terms from insurers with strong credit ratings (A+ or higher) and without the usual onerous coverage conditions/limitations favoured by insurers which have the potential to give rise to coverage disputes. Have options to retain or transfer all or part of the Trust s liability assumed on leaving the CNST, as required on exit from the scheme. Have developed an exit strategy should commercial insurance become unavailable. If seeking to re join the CNST, provision would be required to cover those incidents which occurred during the period of commercial cover. However, the differences in the cover provided needs to be fully evaluated. 10 Many insurers will consider managing and paying these claims, but the additional costs of this need to be considered. 11 In respect of the obligations assumed from the CNST, it may be possible to transfer these to the insurance market, but it may be difficult to obtain these at economic terms. Marsh 13

14 4 Conclusions and recommendations The previous sections have highlighted the key differences between commercial insurance and the CNST, and have shown the factors to consider in any insurance purchasing decision. Each Foundation Trust should scrutinise the cost of membership of the CNST, to ensure that it is meeting their requirements. If seeking alternatives, clarity should be sought on the minimum level of protection which is considered adequate in terms of financial limits, financial security and terms and conditions. Commissioning bodies are likely to require minimum limits on insurance policies, however, it is recommended that standards are also set on the minimum level of terms and conditions acceptable within insurance contracts for Foundation Trusts. Commercial insurance policies can sometimes offer greater flexibility (e.g. through choice of deductible, with the corresponding impact on costs and uncertainty) and can give control back to a local level, although insurers will always levy some control and may remove local control over claims. The implications of this greater flexibility and control, coupled with the loss of the pooled NHS experience, need to be appropriately assessed and any decision-making needs should take into account all the costs of each alternative, the level of protection given, the benefits of change and the costs of the transition. The factors involved in decision making are complex and need full consideration to ensure that Trusts have the protection required in the long term, at an efficient cost. Both the CNST and the commercial insurance market can offer financial indemnity, when this is most needed both by patients who have suffered harm and by Trusts to allow for financial compensation. The decision as to which alternative offers greater protection and value for money will depend on the specific circumstances of each Trust, in terms of clinical specialties, size, claims history, contribution and premium calculations, and attitude to risk. 14 Comparison of the NHS Litigation Authority and the Commercial Insurance Market

15 Marsh 15

16 For further information, please contact your local Marsh office or visit our website at uk.marsh.com Kathryn Anderson David Kennedy The information contained herein is based on sources we believe reliable and should be understood to be general risk management and insurance information only. The information is not intended to be taken as advice with respect to any individual situation and cannot be relied upon as such. Marsh Ltd. is authorised and regulated by the Financial Services Authority for insurance mediation activities only. Copyright 2012 Marsh Ltd All rights reserved GRAPHICS NO