You know what’s a bummer? Getting sued for med mal.

You know what’s a double bummer? Having your carrier deny the claim.

Getting a claim covered seems simple enough. Most doctors have “claims-made” policies. That means you need coverage from the date of the medical event which triggered the claim through the date the claim is made. Normally, that date is when you receive a “love letter” from an attorney demanding money. Or a letter stating they intend to sue you. Or you are sued.

There’s another obscure clause buried deep in many policies which ALSO mandates that the claim must be reported as soon as practicable, but no later than the end of the policy period. The end of the policy period is the anniversary date of your policy. The renewal date. When the clock resets.

Let’s make it real.

Assume you make your annual premium payments each year without delay. Off to a good start. In this example, your policy runs from January 1st to December 31st. Note, many policies do NOT use the calendar year for its length of coverage. The anniversary date may cycle with when you started your practice, or when the group started its practice, but not always. It’s a date you should know and keep handy.

Now, you perform a surgery on a patient July 1st. It goes reasonably well, and the patient is lost to follow-up after sutures are removed.

Unbeknownst to you, a lawyer requests medical records on September 1st. Your office sends the records.

Your office receives and accepts a summons for lawsuit on December 21st when you are on your annual two-week vacation.

This lovely piece of paper greets you on your return. Welcome back. You notify your carrier about the claim.

It denies the claim arguing that you reported the claim in the NEW policy year. Too late. Claim is denied. Your carrier reminds you that you pay from January 1st to December 31st. Even though you have prepaid for the next year, the claim was reported in the new policy period.

Based on these facts, you may eventually prevail in getting the carrier to pay for your defense and any settlement or judgment. You were, of course, out of town. And you DID notify the carrier as soon as practicable. You’re not Nostradamus. Whether or not the carrier will pay the bills will depend on the carrier’s reputation and track record, how the law vis a vis policy language in your state is interpreted, and the facts of your case.

Let’s add one more wrinkle to this example.

When the lawyer requested records on September 1st, assume it included language:

“Please be advised I represent Mr. John Doe in his healthcare liability claim under Chapter blah blah of State Civil Practices and Remedies Code for injuries and damages sustained under your care. Enclosed is authorization to send me copy of the full medical record. And so on.”

Note, there was no demand for money at this point. Just a request for records and a hint that a demand for money will be forthcoming based on the records.
Now the carrier has a better argument that you did not timely report a potential claim that has been marinating for four months.

The argument against paying for your defense just tilted in favor of the carrier.

Rut Ro.

The simple take-home points are these:

(a) Understand if you have an occurrence or claims-made policy.
(b) Know when your policy renews.
(c) Make sure you report any claim to the carrier ASAP.
(d) Do not delay reporting beyond the anniversary date
(e) Understand the definition of a claim that needs to be reported. It varies from policy to policy and carrier to carrier.

Finally, and most importantly, use a broker who understands this space and can go to bat for you as an advocate. They will go over the details of your policy in person or on the phone. They will educate you. They do not want a carrier denying a claim due to delayed reporting. We can provide names of brokers we consider cream of the crop. They can also go over your current coverage to see if you are overpaying. Or there are coverage gaps. Full disclosure, we are not paid anything by these individuals to sing their praises. They just do good work. Write to us at infonews@medicaljustice.com.com for details. 

Learn how Medical Justice can protect you from medico-legal mayhem… 

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.