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CPHRM Claims

CPHRM Claims and Litigation 2014

Claims process identification, investigation, analysis and classification, reporting, coverage determination, setting reserves, claims management strategies, resolution
IBNR Incurred But Not Reported
PCE occurrence for which a claim can be reasonably anticipated but for which no claim has yet been asserted; event for which there are grounds/contributing factors found after investigation, worthy of compensation (NO INJURY REQUIRED)
Claim Formal notification (generally in writing) that monetary damages are being sought for an alleged injury
Lawsuit formal legal action filed in court
Negligence Elements (4Ds) Duty to exercise reasonable care (Standard of Care); Duty breached; Direct or proximate causation (injury); and Damages resulted
Vicarious liability imputed liability for acts of another; employer for acts of negligence or omissions of it’s employees
Respondeat Superior Employer responsible for the acts of their employees if the alleged wrongful act is within the course and scope of their employment; Employee has to also have been found liable
Ostensible or apparent agency Patient looked to the facility rather than the individual physician for care; the institution held out the independent contractor as an employee (e.g., hospital based physician services)
Corporate negligence Facility responsible for own acts of negligence in failing to ensure that a proper standard of care is upheld; must have known of a defect in procedures and the defect was substantial factor in the patient injury
Timeframe to set initial reserves within 90 days of claim
Loss Ratio formula Losses (paid losses + expenses + reserves)/Paid Premiums
Alternative Dispute Resolution (ADR) a process designed to resolve disputes in a manner that avoids the cost, delay, and unpredictability of the traditional adjudicatory process (arbitration, mediation, negotiation)
Motion for Summary Judgment facts are not in dispute and legal principles suggest there’s going to be a ruling for the defendant
Motion in Limine managing what the jurors will see (may be for not allowing facts to come forward that have nothing to do with case)
Direct Verdict Plaintiff failed to meet their burden of proof
Created by: Camellia Acker Camellia Acker