Medical Malpractice Insurance Glossary
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Liability regardless of fault.
Administrative Defense Coverage
This coverage protects Physicians and Surgeons for legal expenses incurred while defending administrative disciplinary actions , peer review actions, privileges, actions by state licensing boards (OPMC), and investigations involving billing and coding practices.
An individual who sells and services insurance policies in either of two classifications: (1) Independent agent represents at least two insurance companies and (2) services clients by searching the market for the most advantageous price for the most coverage. The agent’s commission is a percentage of each premium paid and includes a fee for servicing the insured’s policy. Direct or career agent represents only one company and sells only its policies. This agent is paid on a commission basis in much the same manner as the independent agent.
The Maximum amount the Insurer will pay for all of the liabilities incurred for a certain insurance policy in a specific policy period.
A policyholders obligation to pay additional money, in excess of premiums, to cover past company losses for which reserves have proven to be inadequate. Trust arrangements and joint underwriting associations are generally assessable.
Assets refer to “all the available properties of every kind or possession of an insurance company that might be used to pay its debts.” There are three classifications of assets: invested assets, all other assets, and total admitted assets. Invested assets refer to things such as bonds, stocks, cash and income-producing real estate. All other assets refer to nonincome producing possessions such as the building the company occupies, office furniture, and debts owed, usually in the form of deferred and unpaid premiums. Total admitted assets refer to everything a company owns. All other plus invested assets equals total admitted assets. By law, some states don’t permit insurance companies to claim certain goods and possessions, such as deferred and unpaid premiums, in the all other assets category, declaring them “nonadmissable.”
Insurance salesperson that searches the marketplace in the interest of clients, not insurance companies.
Independent insurance salesperson who represents particular insurers but also might function as a broker by searching the entire insurance market to place an applicant’s coverage to maximize protection and minimize cost. This person is licensed as an agent and a broker.
Equity of shareholders of a stock insurance company. The company’s capital and surplus are measured by the difference between its assets minus its liabilities. This value protects the interests of the company’s policyowners in the event it develops financial problems; the policyowners’ benefits are thus protected by the insurance company’s capital. Shareholders’ interest is second to that of policyowners.
A written notice, demand, lawsuit, arbitration proceeding, or screening panel in which a demand is made for money or a bill reduction, and which argues injury, disability, sickness, disease, or death of a patient arising from the physician’s rendering or failing to render professional services.
Claims Made Policies provide coverage for claims made in the period the policy is in force. Claims made policies provide coverage only so long as the insured continues to pay premiums for the initial policy and any subsequent renewals. Once premiums stop the coverage stops for any claims not known or made to the insurance company during the coverage period.
Claims Reserves (claims-made policy)
Funds set aside to satisfy those claims that have been reported to the company but not yet resolved or paid.
Claims Reserves (occurrence policy)
An additional reserve must be set aside for incidents that occurred but were not formally reported during the policy year and are expected to be reported after the close of the policy year.
Under a claims-paid policy, premiums are based only on claims settled during the previous year and projected to be settled in the coming year. Many claims-paid policies are assessable for a number of years, or even indefinitely, after a physician has terminated the policy.
Consent to Settle in Favor of the Physician
A provision (also known as the “hammer clause” and “blackmail settlement clause”) found in professional liability insurance policies, that requires an insurer to seek an insured’s approval prior to settling a claim for a specific amount. However, if the insured does not approve the recommended figure, the consent to settlement clause states that the insurer will not be liable for any additional monies required to settle the claim or for the defense costs that accrue from the point after the settlement recommendation is made by the insurer.
Continuing Medical Education (CME)
CME consists of educational programs that keep healthcare providers current on the rapid advancements in medicine.
Date of Incident
The date on which a situation of alleged malpractice took place. Also called “date of occurrence.”
Date of Reporting
The date of reporting is the date on which the incident was reported to the insurance company.
Declarations Page/Cover Page
A component of an insurance policy, usually the first page, that provides information about the property, person(s), or activity(ies) that are insured, policy limits, deductibles, and coverages. Also called a Coverage Summary.
Allows the insured to pay an amount of the “first dollars” of a claim payment and to pay a lower premium for assuming this risk.
A policy provision that describes the Insurer’s obligation for the defense and settlement costs involved in a covered claim.
Refers to the state in which an insurance company receives a license to operate. The company is then regulated by that state’s Department of Insurance.
Electronic Medical Record systems are becoming more prevalent in the medical industry as incentives are put into place for hospitals and medical practices replacing their manual documentation procedures with an EMR system. An EMR system promises more accurate, legible and comprehensive patient data which can ultimately aid in the defense of an Insured and reduce the amount of indemnity payout. Medical practices who are utilizing an EMR system will be eligible for a 2% credit.
An amendment, sometimes referred to as a rider, added in writing to an insurance contract or policy.
Coverage for claims against your PLLC arising from the wrongful acts caused by the PLLC itself. In most cases this is a vicarious liability exposure tied to a claim of malpractice against a physician employed by the PLLC.
Items or conditions that are not covered by the general insurance contract.
The ratio of underwriting expenses (including commissions) to net premiums written. This ratio measures the company’s operational efficiency in underwriting its book of business.
A method of adjusting premiums according to the Insured’s loss history in prior years.
Extended Reporting Period (ERP)
ERP extends the claims-reporting provisions for a specific time period beyond the policy expiration date, for any claims arising from incidents that occurred after the retroactive date and prior to the expiration of the policy. Also called Tail coverage.
First Named Insured
An Insured, typically the primary insurance purchase, who is named in the policy declarations. The First Named Insured has special rights and duties, and also pays premiums and receives return premiums.
Refers to the payment made to the plaintiff for special and general damages assessed against the insured healthcare providers.
A process whereby a healthcare provider informs a patient of the potential benefits, major risks, and alternatives involved in any surgical procedure, medical procedure, or other course of treatment, and obtains the patient’s consent to proceed.
Licensed Practical Nurse (LPN)
LPNs help care for ill or injured people and perform health maintenance duties under the direction of Physicians and Registered Nurses. Most LPNs provide basic bedside care to patients, such as taking their temperature, blood pressure, pulse, and respiration, and applying dressings.
Generally refers to Lloyd’s of London, England, an institution within which individual underwriters accept or reject the risks offered to them. The Lloyd’s Corp. provides the support facility for their activities.
These organizations are voluntary unincorporated associations of individuals. Each individual assumes a specified portion of the liability under each policy issued. The underwriters operate through a common attorney-in-fact appointed for this purpose by the underwriters. The laws of most states contain some provisions governing the formation and operation of such organizations, but these laws don’t generally provide as strict a supervision and control as the laws dealing with incorporated stock and mutual insurance companies.
A substitute physician who temporarily takes the place of a named insured policyholder or physician member of a medical group. This coverage may be contingent upon the policyholder or member physician not practicing during the period in which the Locum Tenens coverage is in effect.
Loss Adjustment Expenses
Expenses incurred to investigate and settle losses.
All methods taken to reduce the frequency and/or severity of losses including exposure avoidance, loss prevention, loss reduction, segregation of exposure units and noninsurance transfer of risk. A combination of risk control techniques with risk financing techniques forms the nucleus of a risk management program. The use of appropriate insurance, avoidance of risk, loss control, risk retention, self insuring, and other techniques that minimize the risks of a business, individual, or organization.
The loss free credit can be applied at the underwriter’s discretion upon review of an applicant’s medical experience, practice/procedure exposures and entire loss. The underwriter has the ability to apply the full available credit or a partial credit can be provided at the underwriter’s discretion.
Refers to the documentation of prior loss experience; a list of previous claims.
A paid loss ratio is the amount of premium a policyholder has paid to the carrier through the years versus the amount the carrier has paid out on his or her behalf for defense and indemnity. For instance, a paid loss ratio of 50% means the carrier has paid out 50% of what they’ve received in premium from a particular policyholder. However, the loss ratio doesn’t take into consideration the carrier’s expense costs, which usually run an additional 25-35%. As a result, a loss ratio greater than 75% usually means the carrier is losing money. An incurred loss ratio is the amount the carrier has paid out (defense and indemnity) plus the amount they expect to pay out (reserves) for a particular policyholder versus the amount of premium a policyholder has paid throughout the years. A policyholder that has never filed a claim has a 0% incurred loss ratio.
Amount set aside to pay for reported and unreported claims. For an individual claim, a case reserve or estimate of the expected loss is set aside.
Medical Professional Liability Insurance (MPLI)
An insurance product that offers financial protection to healthcare providers for liability arising from errors and omissions in the practice of their profession.
Documents detailing information about the medical care received by patients from healthcare providers.
The practice of performing healthcare services beyond the scope of healthcare professional’s formal employment, for other healthcare professionals or organizations.
Mutual Insurance Companies
Companies with no capital stock, and owned by policyholders. The earnings of the company–over and above the payments of the losses, operating expenses and reserves–are the property of the policyholders. There are two types of mutual insurance companies. A nonassessable mutual charges a fixed premium and the policyholders cannot be assessed further. Legal reserves and surplus are maintained to provide payment of all claims. Assessable mutuals are companies that charge an initial fixed premium and, if that isn’t sufficient, might assess policyholders to meet losses in excess of the premiums that have been charged.
New to Practice Discount
Premium credit for MPLI coverage received by new to practice Physicians. Typically, these Physicians have just completed their residency or fellowship training.
Non-assessable Insurance Policy
If an insurance policy is non-assessable, the Insurer cannot assess its policyholders for additional capital contributions if the company has poor underwriting results.
Nose coverage covers claims first made against the physician after the effective date of coverage on the policy. To be covered, such claims must arise out of the physician’s acts or omissions prior to the policy’s effective date and after its retroactive date. (Both dates are shown on the declarations page of the policy.) A final note: Nose coverage is also known as retroactive coverage or prior acts coverage.
Notice of Claim
A letter from the patient or his Attorney notifying a healthcare provider of the intent to sue. This can be in the form of a letter or notice that a lawsuit has already been filed, the form for which may be specified by applicable state law.
Nurse Practitioner (NP)
NPs are Registered Nurses who have completed more advanced education with extensive clinical training. They obtain health histories, perform physical examinations, monitor patients, order and interpret laboratory tests and x-rays, provide health education, and, in some states, may write prescriptions.
Occurrence coverage is insurance that provides coverage for the act when it occurs – regardless of when it is reported. If you had coverage under an occurrence policy in 2000 and the claim is reported today
J.M. Woodworth RRG, Inc. considers part-time as any practitioner working 20 hours or less per week (inclusive of office, administrative duties, & hospital). During the underwriting analysis, it is possible for an applicant to receive premium credits at the underwriter’s discretion.
Premium credit received by applicants for MPLI coverage for part-time practice, since they present a lower exposure than healthcare workers working a full 40-hour workweek.
Physician Assistant (PA)
An allied healthcare professional licensed to practice medicine under a Physician’s supervision. A Physician Assistant’s responsibilities may include conducting physical exams, making diagnoses, and treating illnesses.
A group of allied healthcare professionals that provides hands-on care with little supervision. They have a more significant level of MPL exposure than other allied healthcare professional due to the level of hands-on care that they provide.
The contract between an insurance company and its insured. The policy defines what the company agrees to cover for what period of time and describes the obligations and responsibilities of the insured.
The length of time for which a policy is written.
The amount of money a policyholder pays for insurance protection. The amount is deemed necessary to pay current losses, to set aside reserves for anticipated losses, and to pay expenses and taxes necessary to operate the company during the time period for which the policies are in force. Premiums allow the company to generate a reasonable profit that reinforces future solvency and contributes to the company’s growth. In the case of a reciprocal insurer, the premiums allow the company to offer insurance to new applicants without the need for additional capital contributions.
Premium to Surplus Ratio –
This ratio is designed to measure the ability of the insurer to absorb above-average losses and the insurer’s financial strength. The ratio is computed by dividing net premiums written by surplus. An insurance company’s surplus is the amount by which assets exceed liabilities. The ratio is computed by dividing net premiums written by surplus. For example, a company with $2 in net premiums written for every $1 of surplus has a 2-to-1 premium to surplus ratio. The lower the ratio, the greater the company’s financial strength. State regulators have established a premium-to-surplus ratio of no higher than 3-to-1 as a guideline.
Premium-to-Surplus Ratio (P/S)
The ratio of net written premium to surplus. This ratio reflects a company’s financial strength and future solvency. The ratio should not exceed 3:1.
Primary Care Physician
In a health plan, a Primary Care Physician is selected by enrollees to determine the type of treatment and diagnostic exams needed, and refers enrollees to specialists, if necessary. This physician receives a monthly fee from the managed care organization for each enrollee that chooses him as their Primary Care Physician.
A claims-made liability policy that does not contain a retroactive date and therefore covers claims arising from acts that took place at any time prior to the inception date of the policy—regardless of how far in the past. More often, however, prior acts coverage is written with a retroactive date. A claims-made policy with a retroactive date will only cover claims from acts committed on or after the retroactive date. Retroactive dates may be set at the inception of the policy or some date prior to inception, often called “nose coverage.” In contrast, policies written with full prior acts coverage contain no such limitations.
Profit or Loss
Underwriting results are combined with investment income, expenses and taxes to calculate profit or loss. Actual profit results from underwriting profit plus investment income that exceeds losses, expenses, and taxes or from investment income that offsets the underwriting loss expenses and taxes. Actual loss results if the investment income does not offset the underwriting loss, expenses, and taxes. Actual losses must be offset by drawing on the company’s surplus. Companies offering assessable policies can impose payments on their policyholders to amend the loss.
Reciprocal Insurance Exchange
An unincorporated groups of individuals, firms or corporations, commonly termed subscribers, who mutually insure one another, each separately assuming his or her share of each risk. Its chief administrator is an attorney-in-fact.
An agreement between insurance companies under which one accepts all or part of the risk or loss of the other. Most primary companies insure only part of the risk on any given policy. The amount varies among carriers. The remainder of the policy limits is covered by reinsurance entities. The less primary risk that the company insures, the more premium it has to pay to the reinsurer to cover the remaining policy limits. In general, smaller companies are able to cover only a relatively small proportion of the liability limit. This results in large premium payments to reinsurers. Larger companies can cover a large proportion safely, thus reducing the payments they must cede to reinsurers, which indirectly reduces the cost of insurance to their policyholders.
Reserves-to-Surplus Ratio (R/S)
A ratio that measures a company’s financial ability to pay claims if reserves prove to be inadequate. Such payments must come from the insurer’s surplus. This ratio should not exceed 4:1.
Retroactive Date Inception (RDI)
Refers to the first year of a claims-made policy, where the retroactive date is the same date as the policy’s effective date. Also called first year claims-made coverage.
A systematic approach to identify, analyze, and address potential exposures to financial loss.
This credit is available when the practitioner has voluntarily completed and passed three approved JMW Risk Management courses. The insured can receive the credit in two different ways: 1.} complete and pass at least four approved JMW Risk Management online courses within 60 days of binding, in which the 5% credit will be applied to the current year’s premium; or 2.} complete and pass at least four approved JMW Risk Management online courses subsequent to 60 days of binding, but prior to the expiration date of the policy and receive a 5% credit that will be applied to the renewal term. Insured’s are encouraged to complete and pass as many online Risk Management courses as they wish throughout the policy period, however, only one 5% Risk Management credit can be applied per policy period. Practitioners who have been required to complete and pass the Online Risk Management courses as a subjectivity of coverage are not eligible for the Risk Management credit.
Risk Retention Group
Risk Retention Groups (RRG) were created by the Federal Liability Risk Retention Act of 1981, amended in 1986, to help business and professional organizations obtain liability insurance that had become unavailable or unaffordable. The Act provided for creation of liability insurance companies owned by their members and known as Risk Retention Groups. An RRG domiciled in one state is allowed to operate in any other state without additional licensing.
Risk Retention Groups
Liability insurance companies owned by their policyholders. Membership is limited to people in the same business or activity, which exposes them to similar liability risks. The purpose is to assume and spread liability exposure to group members and to provide an alternative risk financing mechanism for liability. These entities are formed under the Liability Risk Retention Act of 1986. Under law, risk retention groups are precluded from writing certain coverages, most notably property lines and workers’ compensation. They predominately write medical malpractice, general liability, professional liability, products liability and excess liability coverages. They can be formed as a mutual or stock company, or a reciprocal.
Having sufficient assets–capital, surplus, reserves–and being able to satisfy financial requirements–investments, annual reports, examinations–to be eligible to transact insurance business and meet liabilities.
A Physician who has completed residency training in a specialty recognized by the American Board of Medical Specialties (ABMS) or the Bureau of Osteopathic Specialists.
A healthcare provider educated and trained in performing surgical procedures.
The amount by which a company’s assets exceed its liabilities. A company’s surplus allows it to take on risk and serves as a cushion in the event that the losses from that risk exceed the premiums intended to cover the risk. Stated another way, surplus can be used to make up for deficiencies in loss reserves that were set aside from earned premiums. Thus, surplus serves to provide strength and to maintain fiscal integrity in the face of adverse loss experience that was not actuarially anticipated.
Surplus Contributed and Surplus Earned
Surplus contributed is the amount of capital insureds must provide for a mutual company or reciprocal exchange during the early years of the company’s operation. Surplus earned represents the earnings of the company after losses, expenses, and taxes. As the company stabilizes and grows in financial strength, earned surplus from profits is added to the contributed surplus, and the contributed surplus can be returned to the early policyholders.
This supplemental insurance covers incidents that occurred during the “active” period of a claims-made policy but are not brought as claims against an insured, nor reported to the insurer, by the time the claims-made policy has been terminated. Needed at various times including when leaving a claims-made carrier, upon the decision to change claims-made carriers, at the time of retirement, or due to death or total disability of the member. Tail coverage is purchased from an insured’s previous claims-made carrier and is generally 125% to 250% of the prior year’s premium.
The profit or loss of the insurance company, computed by subtracting from earned premium those amounts paid out and reserved for losses and expenses. Any residual amount is called an underwriting profit. If those deductions exceed the earned premium this is called an underwriting loss. Underwriting results do not include investment income
Liability for the acts of someone else.