This is the fourth part in a series of short articles designed to help medical practitioners manage their relationship with insurers. In previous articles we have looked at the framework within which we have to operate (policy reporting conditions) as well as identifying the circumstances that will require early management.
The important thing to bear in mind is that early investigation and preparation of cases in anticipation of claims arising does not have to be to the exclusion of reporting the right cases to insurers; it’s all a matter of timing.
In the first article in this series, we saw that the claimant controls the timetable in the sense he has control over whether and when a complaint or claim is pursued (subject to the Limitation Act, which can time out a case). However, nothing prevents the medical professional from investigating and preparing a case in anticipation. Indeed, sound medical practice encourages or demands this via adverse incident reporting and the like.
Imagine insurers as just another stakeholder in this process. There is an escalation of reporting in clinical risk management which can be instructive as to the type of case to report. A typical reporting condition bears re-stating:
"The Insured shall give immediate written notice (but in any event no later than 45 days after the Insured first became aware of such Claim, or Circumstance) to the Insurer of any Claim first made against the Insured (or any specific event or Circumstance that in the opinion of the Insured may give rise to a Claim made against the Insured) and which forms the subject of indemnity under this Policy. Every Claim, writ, summons or process and all documents relating to the Claim, event or Circumstance shall be forwarded to the Insurer immediately they are received by the Insured."
A collateral benefit of a robust adverse incident investigation is an early clinical view on merits of a case, should one be forthcoming. That will enable a worked-up case to go to insurers within the appropriate time.
I routinely handle the investigation of circumstances and deciding which cases to report. This approach should not lead to wild swings in the attitude of insurers, and we have several examples of this, to include premium reductions over the last 3 years.
So, what does a worked-up case look like? Well, whilst it sounds like a cliché, it is true that each case is different. However, from an insurance perspective, the following features will be addressed in sufficient detail to recognise the risks in the case. Risk is defined as the prospect of success of any case that is advanced, versus the costs of working the case up at that point.
Common features will include:
A few additional comments are appropriate at this early stage:
To be continued…