Risk Management

When Should You Call The Claims Department?

By Paul Weber, JD 

OMIC Risk Manager

Digest, Winter 2002

The OMIC Claims Department frequently receives questions from insureds about when it is necessary to report a claims-related matter and what impact such a report will have on their policy, particularly if the patient does not demand damages. Another area of concern for insureds is the need to report claims to regulatory agencies and hospitals.

Q Why should I report a claims-related matter to OMIC if I have not been served with a summons and complaint?

A When you call OMIC immediately after an incident occurs, we may be able to advise you of steps you can take to keep the situation under control. OMIC’s claims and risk management staff have handled hundreds of ophthalmic claims and are available to assist you and answer questions regarding any matter that you think might have the potential of arising into a claim.

Q What matters must I report to OMIC?

A Your OMIC policy states that you shall report any claim. A claim is defined in the policy as a written notice, demand, cross-claim, or lawsuit (including an arbitration proceeding) which the insured receives resulting from a medical incident. Your OMIC policy is claims made, meaning you are covered only if the policy is in force both on the date the incident causing the claim occurs and on the date the claim is first reported. Therefore, you should report any matter to OMIC as soon as possible to protect your insurance coverage. 

Q Should I report an incident if there is no lawsuit or other written notice or demand from the patient?

A Your OMIC insurance policy also states that you shall report, as soon as practicable, any medical incident that may reasonably be expected to result in a claim. A medical incident is defined as any act or omission in the furnishing of professional services. A report of a medical incident will be deemed notice of a claim and will trigger your insurance coverage for this event. Again, by reporting a medical incident, you are protecting your OMIC insurance coverage.

Q If I report an incident before it becomes a claim, will it affect my record and cause my premium to go up?

A No. Reporting a patient problem or incident (an occurrence with the potential of developing into a claim) that does not develop into a claim will have no effect on your premium. Early notice of an incident shows that you are proactive and risk management conscious.

Q How does OMIC categorize reports from insureds?

A Each matter is unique and how a file is set up, with the exception of a lawsuit, will depend on the nature of the incident or medical event. The status of a file may change over time, and a matter set up as an incident may later become a lawsuit if the insured is served with court papers. It bears repeating that regardless of how a file is set up, insurance coverage is extended only if the policy is in force both on the date the incident causing the claim occurs and on the date the claim is first reported.

Q What duty does OMIC have to report claims to regulatory agencies such as the National Practitioner Data Bank (NPDB), state medical board, and state insurance department?

A OMIC must report a claim to the NPDB if an indemnity payment is paid on an insured’s behalf. When such a report is made to the NPDB, a copy must be sent to the appropriate state medical board. In addition, a very few state medical boards and insurance departments (e.g., Texas) require that all claims be reported regardless of whether an indemnity is paid. By definition, matters set up by OMIC as incident or miscellaneous files need not be reported to these agencies. OMIC staff will advise and consult with an insured before a report is made to any agency.

Q What matters are reported to hospitals and HMOs for credentialing?

A Because OMIC encourages policyholders to report all potential incidents on a precautionary basis, OMIC reports loss history only if a case closed with an indemnity payment or an actual lawsuit was filed. The insured must give written authorization before OMIC sends a loss history report to a hospital or HMO. 

This article is for informational purposes only and is not intended as a modification of the terms and conditions of your OMIC insurance policy. Please contact the Claims Department at (800) 562-6642, ext. 629 or claims@omic.com if you have other questions about reporting a claims-related matter to OMIC.