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CPHRM Claims
CPHRM Claims and Litigation 2014
| Question | Answer |
|---|---|
| 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
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