The claim process is just that . . . a process. It is a series of events. The process may take a few months or several years. There are many variables that factor into why the process may take longer in your claim than it did for the claim of your colleague. You will be required to actively participate in several aspects of the process (for example, if you are required to give a deposition) but often, months may pass without the need for your involvement. TMLT claim staff will keep you updated during the process.
TMLT is notified of a claim.
If the policyholder reports the following, a claim file is set up:
- a notice of claim letter
- a lawsuit
- a written demand from a patient for monetary compensation
If the policyholder reports something other than a notice of claim letter, a lawsuit, or a written demand from a patient, the claim operations department makes note of the report but does not open a claim file. This includes reports of unusual incidents, medical record requests, and oral threats.
Once a claim file is set up, the loss is assigned to a claim supervisor and coverage is entered and verified.
A response letter is sent to the policyholder and the plaintiff's attorney.
The claim supervisor performs a preliminary investigation over the next several months. This includes collecting and reviewing the medical records and referring the case to independent medical consultants for evaluation. During this time, the case may become a lawsuit or it may stay a claim.
If a suit is not filed, the case remains a claim. After the initial investigation, the claim is re-evaluated on a routine basis. A decision is made during this time as to whether the claim can be closed. If no lawsuit is filed or if there is no response from the plaintiff's attorney after the initial claim letter or after TMLT denies the claim, we will often close the claim. At other times, we will wait until the statute of limitations expires before closing the claim.
If a lawsuit is filed, then we assign a defense attorney. The policyholder receives a letter from the claim supervisor advising of the attorney assignment. TMLT also notifies the Texas Medical Board (TMB) when a lawsuit is filed.
Under the direction of the TMLT claim supervisor, the defense attorney now prepares the case for trial by conducting discovery, locating expert witness testimony, and taking depositions. The claim supervisor, the attorney, and the policyholder work together to develop a defense strategy.
After the investigation, the policyholder, the attorney, and the claim supervisor may decide to settle the case. Policyholder consent must be given for any settlement. If settlement is agreed to, negotiations begin. If acceptable terms are reached during settlement negotiations, the case is settled.
The case may also be settled before trial during mediation. At mediation, all parties involved in the suit meet with an independent mediator who helps resolve the case.
If the decision is made to proceed with the trial, a trial date is scheduled.
A trial may last anywhere from a few days to a few months.
If the defense wins at trial, the claim is closed. If the defense loses at trial, TMLT pays the award up to the policy limit. However, if we feel the jury award is excessive or was rendered because of an error at trial, we may appeal the verdict or try to negotiate a fair settlement.
When a claim is closed, TMLT submits a final report to the TMB. If a claim is closed with indemnity payment to the plaintiff, we notify the National Practitioner Data Bank. TMLT also reports claims with indemnity payments of more than $10,000 to the Texas Department of Insurance (TDI). The report made to TDI is for statistical purposes only.
If we decide to appeal a jury verdict, we will continue to defend the policyholder throughout the appellate process.
