CHS INSURANCE PROFESSIONAL LIABILITY HANDBOOK

Transcription

1 CHS INSURANCE PROFESSIONAL LIABILITY HANDBOOK 2009

2 HISTORY OF CHS PROFESSIONAL LIABILITY INSURANCE In 1980 Hartford Hospital developed a professional liability insurance program with the Aetna Life and Casualty Insurance Company where both the Hospital and participating physicians became stakeholders in the plan s financial success. As plan years were closed, the improved loss experience realized by Hartford Hospital and the physicians resulted in a partial return of paid premiums. A program of risk management in which all insureds participated under the direction of a full-time risk manager at the hospital was instituted to reduce incidents, claims and losses. Where special problems were identified, changes in clinical programs to improve care and reduce losses were instituted. In 1984, the hospital and physician risk pools were combined to heighten the level of cooperation between the hospital and physicians in reducing losses. In 1987, Connecticut Health System, Inc. assumed overall sponsorship of the program, designated as the CHS Professional Liability Insurance Program. On 1 October 1987, Meriden-Wallingford Hospital (now MidState Medical Center) and its physicians joined the program. On 1 October 1989, Newington Children's Hospital (now Connecticut Children's Medical Center) and its physicians joined. For the plan years 1981 through 1990, return premiums of approximately $29 million resulting from better than expected loss experiences were made to the program participants. Aetna phased out all of its medical professional liability coverage nationwide prior to 1990 except for the CHS program. In 1990, Aetna indicated its desire to terminate its further participation. CHS Administration, along with representatives of the administration and staff from each CHS hospital, studied several models and major

3 insurance companies before proceeding with a program using the St. Paul Insurance Company. The results of our study led to the creation of CHS Insurance Limited, a Bermuda reinsurance company. The St. Paul eliminated its malpractice insurance line of business effective October 1, The CNA Insurance Company was selected to replace the St. Paul effective October 1, R.C. Knox & Company has been involved with the program since its inception in 1980 as the local agent for CNA which issues the policies. Claims are managed by the CHS Director of Medical Claims Management, Allison Reynolds, in conjunction with the Directors of Risk Management from each of the CHS Hospitals in the program. Elliot Joseph, President & CEO Connecticut Health System, Inc.

4 ABOUT THIS HANDBOOK This handbook has been prepared as a guide to the coverage provided to practitioners by the CHS/CNA Professional Liability Program. For the actual terms of coverage, refer to the policy issued by CNA and available online or by requesting a written copy from Mary Ann Nelligan, Director, CHS Insurance. Should there be any difference in the information between this handbook and the policy, the information in the policy will be deemed to be in effect. PROGRAM CONTACTS For information regarding professional liability insurance, please call Mary Ann Nelligan, Director, CHS Insurance, at (860) or John Byrnes of R. C. Knox & Company, Inc., at (860) s can be directed to Mnelliga@harthosp.org. Claim issues and incident reports should be referred to the following contacts at the physician s respective hospital: Hartford Hospital Allison Reynolds Director, Medical Claims Management MidState Medical Center Elizabeth DeSanto Risk Manager

5 CT Children's Medical Center Elizabeth Starr Risk Manager APPLICATION FOR COVERAGE Insurance under the program is available only upon submission of a completed application. Completed applications should be submitted to Mary Ann Nelligan, Director, CHS Insurance; applications may be sent via the Medical Staff Office along with other credentials. Applications must be submitted at least 30 days before coverage is desired. The policy period is from 1 January through 31 December. CHS reserves the right to deny any applicant s request for coverage. Applications and renewals are subject to review and acceptance by CHS/CNA. ELIGIBILITY FOR COVERAGE Success of the program depends on insuring only practitioners and institutions, which provide quality, care and adhere to sound risk management principles. Only physicians who have active medical staff privileges in a participating CHS hospital are eligible to participate in this insurance program. Members of a group practice are eligible to participate only if all members and the group elect to participate and are accepted.

6 BILLING FOR PREMIUMS The CHS Insurance Department bills in twelve interest-free monthly payments. The bill is sent one month in advance for the insurance premiums. Invoices for physicians are mailed on the first of each month. Full payment is due and payable on the twenty-eighth of each month for the succeeding month. If premium payments become in arrears by 60 days, a notice of cancellation of coverage will be sent, that termination of coverage becoming effective in 90 days from the issuance of the termination notice. Coverage may be reinstated on payment of all premiums that are due and on review by the Underwriting Committee. All questions referencing billing should be directed to Jodi LaTorre, CHS Insurance Department at (860) NEW PHYSICIAN PREMIUM DISCOUNT Physicians new to the practice of medicine receive a 50% premium credit for the first year of practice. PART-TIME PHYSICIAN DISCOUNT Subject to review by the Underwriting Committee, physicians may be eligible for a 50% reduction in premium if their professional activities are limited to twenty hours per week, or a maximum of 1,000 hours per year.

7 DISABILITY / MATERNITY LEAVE / LEAVE OF ABSENCE The premium will be waived if notified within 90 days for the following reasons until the physician returns to practice. Condition Disability Leave of Absence Maternity Leave after 45 days for a minimum of 90 days for a minimum of 45 days In order to obtain the waiver, the physician must notify Mary Ann Nelligan, Director, CHS Insurance, in writing, of the date the leave commences and the date coverage is to be reinstated. The premium is waived for each full month (up to one year) the physician is not in practice. Should physician not meet the required criteria for the free tail, the physician would be responsible for paying the applicable premium should tail coverage be needed. Tail coverage extends indefinitely the time period during which you can report claims under your policy.

8 CLAIMS-MADE COVERAGE The CHS/CNA coverage under the program is "claims-made" coverage. A claims-made policy provides coverage for any potential claims that are reported by you or actual claims that are brought against you during the period of time for which the policy is in effect. A claim which is brought for an action, which occurred when the policy was in effect but for which no notice was given by either the insured or the claimant during the period when the policy was in effect, is not covered. This is why tail coverage is necessary when terminating coverage or changing to a new policy to a new policy which does not cover prior acts. COVERAGE Provides worldwide protection against professional liability claims, which might be brought against you in your practice as a physician or surgeon. Your professional liability protection covers you for damages resulting from: you or your organization providing or withholding of professional services providing or withholding of professional services by anyone whose acts you are legally responsible for including, among others, your employees and volunteer workers when working within the scope of their assigned duties for you your service on a formal accreditation board or similar board or committee

9 Within one month prior to the January 1st onset of a new plan year, you will be given the opportunity to increase or decrease your limits of liability. LIABILITY ASSUMED UNDER CONTRACT Your liability protection includes coverage for professional services liability assumed by contract with an HMO, PPO, and IPA attributable to you or others insured by this policy. LOCUM TENENS COVERAGE Insurance protection is provided free of charge by endorsement for a physician substituting for you to cover professional services rendered on your behalf. Coverage is provided at no additional charge, if the physician who is covered is not engaged in covered medical activities during that period. If the covered physician is to practice elsewhere during that period, special arrangements would be considered to provide coverage to both physicians upon review by the Underwriting Committee. The locum tenens shares in your limits of liability. A locum tenens application for substituting physician must be submitted, in writing, to Mary Ann Nelligan, Director, CHS Insurance prior to the effective date of the locum tenens coverage. The period for which coverage is desired must be established when the application is submitted.

10 Locum tenens coverage is provided up to 90 days in a policy year. Request for longer periods of coverage should be directed to the Director, CHS Insurance at (860) DEFENDANT REIMBURSEMENT Defendant's reimbursement is available for time away from your practice for court appearances for a professional liability suit. The amount of reimbursement is subject to a set schedule of payment. HOW THE LIMITS OF LIABILITY APPLY For group practices, the limits apply separately to each covered physician and to the group itself. For solo practitioners, operating as a professional corporation, the physician and the corporation share one limit.

11 OPTIONAL REPORTING ENDORSEMENT/TAIL COVERAGE DEATH, DISABILITY, OR RETIREMENT In order to obtain the tail coverage, the physician must notify Mary Ann Nelligan, Director, CHS Insurance, in writing, of the date the claims-made coverage is to be terminated. Upon terminating your claims-made coverage, in order to have coverage for claims reported in the future which arise out of your practice while covered under the CHS Program, you must do one of the following: purchase "prior acts" coverage from your new insurer which would then cover claims arising from the time that your practice was covered by your CHS/CNA claims made policy for which neither filing or notice of a potential claim had been made, or purchase the tail coverage; this tail coverage extends indefinitely the time period during which you can report claims under your policy The tail coverage will be provided at no cost to: your estate if you die while covered under the program you if you retire completely from the practice of medicine after age 55 and have been continuously insured with the Connecticut Health System Independent Staff Physicians Program for the last five years before you retire. Proof of retirement such as letter to patients, notice of practice closing in newspaper, etc, must be supplied.

12 The tail coverage will be provided to you at no cost if you meet the following requirements for total disability: must be totally and continuously disabled for at least six consecutive months as a result of sickness or accidental bodily injury a physician, not yourself or a member of your group, or a member of your immediate family, must certify that you are unable to perform the duties of your former "occupation," defined by specialty If, for any reasons other than death, disability, or retirement, CNA or you choose to cancel your coverage, you have the right to purchase tail coverage. This tail extends indefinitely your right to report a claim for an incident occurring during the policy period. The tail coverage must be requested, in writing, to the Mary Ann Nelligan, Director, CHS Insurance, within 30 days after the policy ends. You may choose limits comparable to what you presently have, or lower limits, if available. You cannot elect higher limits. A tail application will be sent to you from the CHS Insurance Department upon leaving the program. After leaving the CHS/CNA insurance program, you may request reinstatement of your coverage or readmission to the program, these requests will be reviewed by the CHS Underwriting Committee on an individual basis. Reinstatement and/or readmission are not automatic.

13 INCIDENT / CLAIMS REPORTING The physician and the claims manager are key persons in deterring claims/lawsuits. The effectiveness of the program depends on prompt notice by the physician to the risk manager of any event that might conceivably give rise to the claim against the physician or the hospital. The physician should advise their hospital s risk manager as soon as possible after an incident or untoward patient outcome is known to have occurred. Reporting indicators: any untoward outcome or residual injury, including residual, that is a known risk of procedure inquiries from patient or an attorney for copies of medical records except when you are certain that the request is for Workers' Compensation, automobile accidents, etc. any letter from an attorney who requests that the letter be turned over to your insurance carrier; DO NOT call the attorney to inquire what the basis of the letter is a writ, summons and complaint which requires you to appear in court a subpoena requiring you to testify or have a deposition taken except when you are certain that the request is for Worker's Compensation, automobile accidents, etc.

14 SETTLEMENT OF CLAIMS / SUITS By agreement with the insurance carrier, no settlement offer may be made by the carrier without the expressed approval of the Director of Medical Claims Management. When the insurance carrier feels that a settlement offer should be made, a discussion of all the facts will be communicated to the Director of Medical Claims Management who will then meet with the insured. Any approval will include the maximum dollars that the carrier can offer. When there is a lack of accord between you and the insurer regarding defense versus settlement, either party may request that the Claim Review Committee, composed of physicians and administrators, be convened. A case manager will be selected to review all of the medical records and present the facts to the committee. You will be expected to be present to answer questions or clarify any issues. The finding of the committee will be used to help determine the best way to manage defense or settlement of the case.

15 CHS PROFESSIONAL LIABILITY INSURANCE COMMITTEES UNDERWRITING COMMITTEE There is a single CHS Underwriting Committee covering the program for all facilities and physicians with representatives from administration, medical staff, risk management and finance. This committee develops criteria for participation in the plan, reviews participant eligibility and classification, reviews claims, develops risk management stragegies and educational programs, evaluates the financial status of the program, and addresses concerns of physicians regarding coverage. CHS OVERSIGHT COMMITTEE The Oversight Committee consists of representatives from each hospital s administration, medical staff and risk management areas, as well as the insurance carrier and actuaries. This committee will meet quarterly, and reviews the reserves of the captive and annual losses, develops strategy. CLAIM REVIEW COMMITTEE The Claim Review Committee is convened when there is a disagreement between CNA and the hospital and/or physician as to whether to settle or defend a particular claim. The decision of the committee, which is composed, of physicians and hospital administrators, will be used to help determine the best way to manage defense or settlement of the case.

16 CLASSIFICATION OF PHYSICIANS Premium Premium Medical Specialties Class Medical Specialties Class Allergy IA Gastroenterology Diagnostic I Anesthesiology III Invasive II Administrative I Gynecology Cardiology Major Surgery V Diagnostic I No Surgery I Pediatric II Pregnancy Termination VI Cardiovascular Disease Hematology I Invasive III Non.Invasive I Infectious Disease I Pediatric III Dentistry Internal Medicine General I Major Invasive Procedures II Oral & Maxillofacial III Minor Invasive Procedures I Dermatology Neonatal No Surgery IA No Surgery II Surgery II Surgery V Diabetics IA Nephrology I Emergency Medicine Neurology I No Surgery III Surgery V NICU No Surgery II Endocrinology I Surgery V Family Medicine I Nuclear Medicine I

17 CLASSIFICATION OF PHYSICIANS Premium Premium Medical Specialties Class Medical Specialties Class Obstetrics & Gynecology VIII Preventive Medicine I Oncology Psychiatry IA No Surgery I Surgery IV Psychiatry/Rehab I Oncology.Hematology I Pulmonary Disease I Critical Care II Ophthalmology Major Surgery IIA No Surgery I Radiation/Oncology II Orthopedics Radiology No Surgery I Diagnostic I Podiatry III Interventional Vascular II Surgery VIA Invasive II Osteopathic Medicine I Rheumatology I Otothinolaryngology IV Surgery Bariatric VI Pathology IA Cardiothoracic VIlA Consultant I Pediatrics General Vl No Surgery I Hand IV Surgery V Neurological VII Ophthalmology IIA Pediatric Neurological VII Plastic V Physiatry I Urological III Peripheral Vascular VIlA PICU No Surgery I Surgery V

18 PROFESSIONAL LIABILITY INSURANCE RATES $1,000,000/$3,000,000 LIMITS OF LIABILITY EFFECTIVE 1 January 2009 LEVELS CLASS FIRST SECOND THIRD FOURTH FIFTH IA $ 4,595 $ 8,379 $ 11,012 $ 12,200 $ 13,182 I $ 5,713 $ 10,417 $ 13,692 $ 15,168 $ 16,390 IIA $ 7,029 $12,817 $ 16,845 $ 18,661 $ 20,165 II $ 8,786 $16,021 $ 21,057 $ 23,327 $ 25,206 III $11,129 $20,293 $ 26,672 $ 29,547 $ 31,927 IV $14,935 $27,232 $ 35,793 $ 39,651 $ 42,845 V $22,258 $40,586 $ 53,344 $ 59,094 $ 63,854 VIA $21,457 $38,292 $ 58,743 $ 63,490 $ 68,771 VI $24,118 $43,978 $ 57,802 $ 64,033 $ 69,190 VIIA $26,519 $48,357 $ 63,563 $ 70,416 $ 76,082 VII $37,944 $65,309 $ 83,704 $ 92,727 $ 100,196 VIIl $47,456 $81,681 $104,688 $115,972 $125,314

19 PROFESSIONAL LIABILITY INSURANCE RATES $2,000,000/$5,000,000 LIMITS OF LIABILITY EFFECTIVE 1 January 2009 LEVELS CLASS FIRST SECOND THIRD FOURTH FIFTH IA $ 4,837 $ 8,820 $ 11,592 $ 12,842 $ 13,876 I $ 6,014 $10,966 $ 14,413 $ 15,966 $ 17,252 IIA $ 7,399 $13,491 $ 17,732 $ 19,643 $ 21,226 II $ 9,249 $16,864 $ 22,165 $ 24,554 $ 26,532 III $11,715 $21,361 $ 28,076 $ 31,102 $ 33,608 IV $15,721 $28,665 $ 37,676 $ 41,738 $ 45,100 V $23,430 $42,722 $ 56,152 $ 62,204 $ 67,215 VIA $22,586 $40,307 $ 61,835 $ 66,832 $ 72,391 VI $28,153 $51,335 $ 67,473 $ 74,746 $ 80,767 VIIA $32,656 $59,548 $ 78,273 $ 86,711 $ 93,689 VII $39,941 $68,746 $ 88,110 $ 97,607 $ 105,470 VIIl $49,953 $85,980 $110,198 $122,076 $131,910

20 PROFESSIONAL LIABILITY INSURANCE RATES $3,000,000/$6,000,000 LIMITS OF LIABILITY EFFECTIVE 1 January 2009 LEVELS CLASS FIRST SECOND THIRD FOURTH FIFTH IA $ 5,021 $ 9,156 $ 11,912 $ 13,290 $ 14,405 I $ 6,842 $12,476 $ 16,232 $ 18,110 $ 19,629 IIA $ 7,681 $14,005 $ 18,222 $ 20,330 $ 22,035 II 9,601 $17,507 $ 22,777 $ 25,412 $ 27,543 III $12,161 $22,175 $ 28,851 $ 32,189 $ 34,888 IV $18,562 $33,846 $ 44,035 $ 49,130 $ 53,250 V $24,323 $44,350 $ 57,702 $ 64,377 $ 69,776 VIA $24,359 $43,472 $ 66,832 $ 71,829 $ 78,075 VI $28,904 $52,704 $ 68,571 $ 76,504 $ 82,921 VIIA $33,780 $61,602 $ 80,147 $ 89,425 $ 96,920 VIl $41,592 $71,589 $ 91,586 $ 101,585 $109,831 VIll $51,713 $89,008 $113,872 $126,304 $136,556