What is considered a claim and what am I require to report?
According to your policy, a claim can be any of the following:
- A demand for compensation — any written communication from or on behalf of a patient that seeks monetary payment or other compensation because of a perceived error in treatment or an unexpected outcome.
- A notice of claim letter — a letter that refers to Civil Practice and Remedies Code Section 74.052 or refers to a notice of claim. Upon receipt of a 74.052 letter, a physician and his or her insurer have 60 days to investigate and evaluate the patient's claim.
- A lawsuit — will contain a citation (which informs you of a lawsuit) and a petition (which lists the plaintiff versus the defendant). A lawsuit will also include the allegations made against you. Once you are served with a citation and petition, TMLT has a limited time to respond by retaining a defense attorney to file an answer on your behalf.
If you receive any of the above items, contact the TMLT Claims Department at 800-580-8658 as soon as possible. We may have limited time to investigate and evaluate the claim. Any delay in reporting could compromise your defense.
If you are reporting a Medefense or Cyber Liability claim you must report it to TMLT no later than 60 days from the date you became aware of the claim.
Although not considered a “claim” that would trigger coverage under your policy, you may want to report the following situations to seek advice to possibly prevent the matter from evolving into a claim:
- Unexpected outcome — any complication or failure of treatment in which the patient or a patient’s family member may have expressed disappointment with the outcome or if you suspect that a claim may be asserted in the future.
- Records request — a request for a patient’s medical records may come from the patient, the patient’s spouse, an attorney, a record service, or from a court reporting service in the form of a subpoena. Requests for records should include an authorization signed by the patient or by the patient’s legal representative. It is best to respond to a request as soon as possible. If you suspect that the records request is for potential or ongoing litigation, or if you question the validity of the records request, you should contact TMLT for advice.
- Request for deposition — a deposition is testimony given under oath before a court reporter. You may be served a subpoena for oral deposition, or an attorney may contact you directly. If you are asked to give testimony regarding a patient, particularly if that patient is suing another health care professional, please contact the TMLT Claim Operations Department immediately. Depositions can potentially become claims and you should be properly represented at any such proceeding.
How do I report a claim?
Report the claim to TMLT by calling 800-580-8658. Please allow about 20 minutes for the report and have whatever notice you received available for reference. It may also be helpful to have the patient’s medical record available.
Fax to 512-328-8067 or send by overnight mail a copy of the notice of claim letter or the lawsuit. Do not fax your medical records. Note that if you are served with a lawsuit, your TMLT policy requires as a condition of coverage that all such lawsuit papers be delivered to TMLT within 10 days of service or receipt of the lawsuit papers, and that you must obtain a delivery receipt from TMLT.
“Delivery of lawsuit papers means sending by certified mail with return receipt requested, personal delivery, messenger, or electronic transmission. Proof of delivery of the lawsuit papers, however, may only be established by the obtaining a written receipt of such delivery from the Trust.”
Gather a complete and unaltered copy of all pertinent medical records, including a copy of the hospital chart and any prior or subsequent treatment records. Mail a copy of these records to TMLT as soon as possible.
I have reported a claim. What happens next?
Once a notice of claim is reported, the loss is assigned to a claim supervisor and coverage is entered and verified. Once the claim file is set up in our system, the following occurs:
- A letter is sent to the policyholder requesting a copy of all medical records regarding the physician’s care of this patient.
- A response letter is sent to the plaintiff’s attorney or pro-se plaintiff requesting specific allegations, damage information, and a medical authorization that when signed by the patient, allows us to request the pertinent medical records;
- If the new loss is a lawsuit, the Texas Medical Board (TMB) is notified;
- If a lawsuit has already been filed, then we dispense with the response letter to the plaintiff’s attorney. We assign a defense attorney to answer the lawsuit and defend the physician. The policyholder receives a letter from the claim supervisor advising of the attorney assignment.
The average time to complete this from the day the loss is reported is about 5-10 working days.
Do not discuss the case with anyone except a TMLT claims representative or the attorney assigned to defend you.
Maintain your original medical records in a secure place for future reference. Do not make any additions, deletions, or any other type of alteration to the medical records. Secure any other pertinent information or items in your possession, such as billing records, x-rays, hospital charts, etc.
All correspondence to and from TMLT and your assigned attorney should be kept in a separate and secure file. These items should not be co-mingled with the original medical chart on the patient. Do not release these materials to anyone unless cleared through your assigned attorney or the TMLT Claims Operations Department.
The TMLT claims representative assigned to your case will keep you fully informed as the case proceeds, both directly and through your assigned attorney. If you have questions, do not hesitate to call your claim supervisor.