CPHRM Claims and Litigation 2014
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| Claims process | identification, investigation, analysis and classification, reporting, coverage determination, setting reserves, claims management strategies, resolution
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| IBNR | Incurred But Not Reported
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| 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)
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| Claim | Formal notification (generally in writing) that monetary damages are being sought for an alleged injury
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| Lawsuit | formal legal action filed in court
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| Negligence Elements (4Ds) | Duty to exercise reasonable care (Standard of Care); Duty breached; Direct or proximate causation (injury); and Damages resulted
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| Vicarious liability | imputed liability for acts of another; employer for acts of negligence or omissions of it’s employees
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| 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
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| 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)
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| 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
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| Timeframe to set initial reserves | within 90 days of claim
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| Loss Ratio formula | Losses (paid losses + expenses + reserves)/Paid Premiums
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| 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)
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| Motion for Summary Judgment | facts are not in dispute and legal principles suggest there’s going to be a ruling for the defendant
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| 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)
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| Direct Verdict | Plaintiff failed to meet their burden of proof
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