The claim process
The claim process may take a few months or several years. You will be required to participate in several steps of the process (such as giving a deposition), but often months may pass without the need for your involvement. TMLT claims staff will keep you updated.
- 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; or
- 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 claims department makes note of the report but does not open a claim file in most instances. 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 claims supervisor and coverage is entered and verified.
- A response letter is sent to the policyholder and the plaintiff’s attorney.
- The claims supervisor investigates the claim 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 remain as a claim.
- If a suit is not filed, the case remains a claim. After the investigation, the claim is re-evaluated on a routine basis. At this time, we will often close a claim if:
- no lawsuit is filed;
- no response from the plaintiff’s attorney; or
- TMLT denies the claim.
- If a lawsuit is filed, then we assign a defense attorney. The policyholder receives a letter advising of the attorney assignment. TMLT also notifies the Texas Medical Board (TMB) when a lawsuit is filed.
- Under the direction of the TMLT claims supervisor, the defense attorney prepares the case for trial by conducting discovery, locating expert witness testimony, and taking depositions. The claims supervisor, the attorney, and the policyholder work together to develop a defense strategy.
- After the investigation, the policyholder, the attorney, and the claims supervisor may decide to settle the case. In most instances, policyholder consent must be given for any settlement.
- If settlement is warranted and physician consent is granted (where applicable), negotiations begin. If acceptable terms are reached during negotiations, the case is settled.
- The case may also be settled before trial during mediation. At mediation, all parties meet with an independent mediator who may help resolve the case.
- If the decision is made to proceed with the trial, a date is scheduled.
- The length of a trial varies by the complexity and the number of parties involved.
- If the defense wins at trial, TMLT may be able to close the claim file. However, the plaintiff may appeal the verdict. If the plaintiff wins at trial, TMLT and defense counsel evaluate the case to determine if there is a legal basis to appeal. Such an appeal may result in a new trial or an opportunity to settle the case.
- 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.
- If we decide to appeal a jury verdict, we will continue to defend the policyholder throughout the appellate process.