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Medical professional liability insurance and its relation to medical error and healthcare risk management for the practicing physician.

PURPOSE: To review the history and current issues surrounding medical professional liability insurance and its relationship to medical error and healthcare risk management. DESIGN: Focused literature review and authors' experience. METHODS: Medical professional liability insurance issues are reviewed in association with the occurrence of medical error and the role of healthcare risk management. RESULTS: The rising frequency and severity of claims and lawsuits incurred by physicians, as well as escalating defense costs, have dramatically increased over the past several years and have resulted in accelerated efforts to reduce medical errors and control practice risk for physicians. Medical error reduction and improved patient outcomes are closely linked to the goals of the medical risk manager by reducing exposure to adverse medical events. Management of professional liability risk by the physician-led malpractice insurance company not only protects the economic viability of physicians, but also addresses patient safety concerns. CONCLUSIONS: Physician-owned malpractice liability insurance companies will continue to be the dominant providers of insurance for practicing physicians and will serve as the primary source for loss prevention and risk management services. To succeed in the marketplace, the emergence and importance of the risk manager and incorporation of risk management principles throughout the professional liability company has become crucial to the financial stability and success of the insurance company. The risk manager provides the necessary advice and support requested by physicians to minimize medical liability risk in their daily practice.

Delivery of Health Care↗

Professional liability insurance for health care organizations--several significant considerations.

The purchase of professional liability insurance coverage represents one of the more important financial and administrative decisions in terms of managing a health services organization. This manuscript outlines a decision process for evaluating and determining the most viable option(s). Also addressed are some significant caveats in assessing the strengths and weaknesses of various coverage options.

Decision Making, Organizational↗

The medical liability insurance crisis: how it began.

Economic pressures, awareness that physicians can be sued, improved medical care, and increased patient expectations have led to the skyrocketing liability insurance costs physicians face today. In the early days when the doctor could offer hope but little medicine, patients were not inclined to sue for medical "failures." But with the Great Depression, World War II, more recent medical advances changed the patient-physician relationship. Patients had gained the expertise of specialists, but often lost the personal relationship they once shared with their primary physician. Thus, when treatments were unsuccessful, the patient often-times blamed the physician. Insurance premiums (and patient costs) increased, while patients became even more aware that physicians were covered by insurance. This article reviews key economic, medical, and social events that led to the present medical liability insurance crisis.

Costs and Cost Analysis↗

The forgotten third: liability insurance and the medical malpractice crisis.

Although the most visible manifestations of medical malpractice involve patient safety and the legal process, the availability and affordability of liability insurance largely determine the direction of medical malpractice policy. Scientific and industrial developments since the first modern malpractice crisis in the 1970s reveal major problems with the structure and regulation of liability insurance. Comprehensive reforms that approach medical malpractice insurance as a health policy problem are needed, and the Medicare program may have a major role to play.

Cost Control↗

Availability of physician services in Florida, revisited: the effect of the professional liability insurance market on access to health care.

BACKGROUND: Access to care remains a key part of improving health care outcomes in the United States. Recent reports have suggested that the number of physicians able to meet the demands for access to care may be decreasing. METHODS: We surveyed physicians practicing in rural and urban/suburban areas of Florida in 2004 to determine whether changes were occurring in health care service delivery. Secondary outcomes assessed included changes in professional liability insurance and their possible effects on changes in service delivery. RESULTS: Overall, 727 (54.4%) of responding physicians stated that the delivery of services had been decreased or eliminated in the previous year. The most commonly eliminated services were nursing home coverage (42.1%), vaginal deliveries (29.1%), cesarean deliveries (26.0%), emergency department coverage (22.8%), and mental health services (21.2%). Surgical specialists (70.2%) and general surgeons (68.5%) were the groups with the highest number of decreased or eliminated services, but this trend was broad, with 63.6% of obstetrician/gynecologists and 60.2% of family medicine physicians also decreasing or eliminating services. Decreases in services seem to be related to changes in professional liability insurance premiums when assessed by both percentage of change and total premium increases for physicians. Rural and urban/suburban physicians did not differ significantly in these assessments. CONCLUSION: The findings suggest that physicians across Florida have continued to decrease or eliminate important health services and that these decreases seem to be related to the difficulty of finding or paying for professional liability insurance.

Florida↗

Professional liability insurance in obstetrics-gynecology.

A geographically stratified sample of Fellows and Junior Fellows of The American College of Obstetricians and Gynecologists (ACOG) responded to a questionnaire, describing the source, coverage, and cost of their professional liability insurance, and the effects this had on patterns of practice. Most physicians carry primary professional liability coverage, although 6% do not. The majority pay less than $8000/year for a wide variety of dollar coverages. Less than half of the surveyed obstetrician-gynecologists carry excess/umbrella liability insurance, and a majority pay less than $2000/year for this coverage. The liability problem has not had a substantial effect on restricting the number of obstetrician-gynecologists, but it has had a major effect on patterns of practice.

California↗

Pulling the coverage trigger: the temporal condition of liability insurance.

Timing issues will continue to be at the forefront of insurance coverage disputes for a long time, and may impact not only the question of which insurer is responsible for a particular loss, but also whether any coverage exists at all. For example, if a policyholder has self-insured for any period, the timing issue may well determine whether purchased liability insurance will afford any protection for the loss. Though courts have provided useful guidelines, in order to determine coverage the facts of each case must be carefully examined, particularly the policy language and the nature of the injury on which the claim is founded. When there are difficult timing questions, one viable approach may be for the policyholder to select a "target" insurer to sue for coverage, based in part on the timing analysis, and leave to the targeted insurer the task of seeking contribution from all other carriers potentially responsible for covering the loss.

Eligibility Determination↗

Providers issue brief: nursing home liability insurance: year end report-2003.

States have been plagued in recent years by dramatic increases in nursing home liability insurance premiums and the flights of insurance carriers. This has forced many nursing homes to operate with substandard levels of coverage or sometimes no coverage at all. As this crisis worsens, many states are taking action to protect both nursing home providers and residents.

Health Policy↗

Medicare program; third party liability insurance regulations. Final rule with comment period.

This final rule with comment period removes Sec. 411.54(c)(2) and a portion of Sec. 489.20(g) from our regulations. These regulations were held by a court to be inconsistent with the Medicare Secondary Payer provisions that are found in section 1862(b)(2)(a) of the Social Security Act. Specifically, the court held that Sec. 411.54(c)(2) and a portion of Sec. 489.20(g) are unenforceable to the extent that these regulations require providers and suppliers to only bill Medicare and prohibits them from billing a liability insurer or asserting or maintaining a lien against a beneficiary's liability insurance settlement during the "promptly" period.

Cost Sharing↗

Liability insurance: can hospitals afford a roll of the dice?

The rise in hospital malpractice claims has greatly affected hospital liability insurance. Increasing premium costs and the shrinking availability of coverage have been some of the effects hospitals have felt. The two most promising approaches for dealing with this problem are increased risk management and changes in tort law. These solutions allow insurance companies to calculate the risk, leading to greater predictability.

Costs and Cost Analysis↗

Impact of the medical professional liability insurance crisis on access to care in Florida.

BACKGROUND: Almost half of the US states face serious problems with professional liability insurance (PLI). Despite this, little is known about how this crisis is affecting access to care, particularly in rural areas. METHODS: We surveyed physicians practicing in rural Florida in 2003. The primary assessment was on changes in health care delivery by service type and specialty. Secondary outcomes included changes in PLI premiums and the effect of changes in premiums on service delivery and practice satisfaction. RESULTS: Four hundred eleven (52.6%) of 781 physicians decreased or eliminated health care services during the past year. Overall, 73 (61.3%) of 119 decreased or eliminated vaginal deliveries; 60 (52.6%) of 114, cesarean sections; 186 (51.7%) of 360, hospital-based surgical procedures; 209 (46.4%) of 450, emergency department coverage; 103 (41.7%) of 247, endoscopic procedures; 187 (40.9%) of 457, office-based surgical procedures; and 105 (34.5%) of 304, mental health services. Elimination of services was highest for general surgeons (78.4%), surgical specialists (73.6%), and obstetricians/gynecologists (70.2%). Premiums for PLI rose a mean of 93.5%. Difficulty finding or paying for PLI was listed as an important factor by those reducing or eliminating services and by those planning to leave the community within the next 2 years. CONCLUSIONS: The current crisis in medical PLI in Florida has a major impact on the availability and delivery of health care services to rural areas. Given the number of states that are experiencing similar insurance market upheavals, adverse effects on access to care are likely occurring nationwide.

Adult↗

Limitations of liability insurance.

In the unfortunate event that you are sued for malpractice, the following suggestions could maximize the benefits of your professional liability insurance policy: Do not contact the claimant, because any statements you make can be used against you in a suit. Provide the insurer with as much information as possible. Monitor the case regularly by contacting the insurance adjuster assigned to the case and request copies of all documents generated. Communicate your feelings with the company about defending or settling the case. If you completely violated a standard of care such as giving an IV push medication to the wrong patient because of failure to check the patient's name bracelet, try to settle this case out of court. A jury would not likely be sympathetic to a nurse who injured a patient in this manner. Review the entire medical record and discuss your analysis with your attorney. Remember, as a policyholder, you have the right to demand that your claim be handled by a competent, professional lawyer. Unlike other professionals, attorneys are not required to have national certification. Defendants have the right to ask assigned attorneys about their malpractice experience. Does the attorney have a working knowledge of the procedures and technical jargon concerning the case? How many similar cases has the attorney handled? You have a right to these answers.

Critical Care↗

The many faces of the liability insurance crisis.

The purpose of this column is to provide an overview of some of the issues and arguments encompassed in the liability insurance crisis, and to impress upon nurses that they can no longer view them as relevant to physicians and hospitals only. This brief overview cannot cover all you need to know before making decisions about insurance or forming strategies to address your state regulations. It is intended to provide you with an impetus to work within your state nurses' association to learn more.

History, 20th Century↗

Analysis of your professional liability insurance policy.

The most important lessons for the physician to learn in regard to his professional liability insurance coverage are the following:1. The physician should carefully read his professional liability policy and should secure the educated aid of his attorney and his insurance broker, if they are conversant with this field.2. He should particularly read the definition of coverage and carefully survey the exclusion clauses which may deny him coverage under certain circumstances.3. If the physician is in partnership or in a group, he should be certain that he has contingent partnership coverage.4. The physician should accept coverage only from an insurance carrier of sufficient size and stability that he can be sure his coverage will be guaranteed for "latent liability" claims as the years go along-certainly for his lifetime.5. The insurance carrier offering the professional liability policy should be prepared to offer coverages up to at least $100,000/$300,000.6. The physician should be assured that the insurance carrier has claims-handling personnel and legal counsel who are experienced and expert in the professional liability field and who are locally available for service.7. The physician is best protected by a local or state group program, next best by a national group program, and last, by individual coverage.8. The physician should look with suspicion on a cancellation clause in which his policy may be summarily cancelled on brief notice.9. The physician should not buy professional liability insurance on the basis of price alone; adequacy of coverage and service and a good insurance company for his protection should be the deciding factors.

Insurance↗

The state of electroconvulsive therapy in Texas. Part 2: contact with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating equipment.

Since mid-1993, all ECT treatments performed in the state of Texas (except for United States government hospitals) must be reported every quarter to the Texas Department of Mental Health and Mental Retardation (TXMHMR) on a data collection form provided by the Department. Part 1 of this paper reviewed that data. This paper reviews the responses to questionnaires and contacts made with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating devices regarding their experience with ECT in Texas. Questionnaires were sent to physicians and hospitals that had not performed ECT during the final two quarters of the review period. Medical liability insurance companies and the manufacturers of the stimulus generating equipment used in ECT were contacted regarding their experience with liability claims. The results indicate that medical liability in regards to the performance of ECT is extremely low. Physicians and hospitals that stopped performing ECT did so for reasons other than medical liability.

Adult↗

Medicare program, services covered under automobile medical, no-fault, or liability insurance; services furnished to ESRD beneficiaries who are covered under employer group health insurance--Health Care Financing Administration. Final rule.

These regulations set forth policies and procedures on coverage of services that are reimbursable under automobile medical, no-fault, or liability insurance, and services to end-stage renal disease (ESRD) beneficiaries who are also covered under employee group health plans. The regulations are necessary to implement section 953 of the Omnibus Reconciliation Act of 1980 and section 2146 of the Omnibus Budget Reconciliation Act of 1981. The first of these sections excludes from Medicare coverage any services for which payment has been made or can reasonably be expected to be made under an automobile or liability insurance policy or plan or under no-fault insurance. The second section makes Medicare benefits secondary to benefits payable under an employer group health plan for services furnished to ESRD beneficiaries during a specified period of up to 12 months. The intent is to conserve Medicare funds and prevent duplicate payments by Medicare.

Centers for Medicare and Medicaid Services, U.S.↗