Medical Malpractice Settlement Report

RICHARD H. BRYAN Governor LARRY D. STRUVE Director STATE OF NEVADA DAVID A. GATES Commissioner of Insurance JEANNE L. BOTTS Deputy Commissioner # DEPARTMENT OF COMMERCE INSURANCE DIVISION 201 South Fall Street Carson City, Nevada 89710 (702) 885-4270 BULLETIN 86-002 March 27, 1986 # MEDICAL MALPRACTICE SETTLEMENT REPORT NRS 690B.045 requires insurers providing liability insurance for a "practitioner of the healing arts" as defined pursuant to Chapters 630-640 of NRS, to file with the appropriate licensing board a report detailing the circumstances of the malpractice. The report to the licensing board is required only when the claim's settlement, award, or judgment is $5,000 or more. NRS 690B.050 requires a report to the Division of Insurance in addition to the licensing board where the insured is a physician licensed pursuant to Chapter 630 of NRS. The requirement to report is conditioned upon the existence of a liability policy covering acts of professional malpractice and a settlement, award, or judgment being reached. It should be noted that there is no minimum settlement amount threshold under NRS 690B.050. All claims must be reported within 30 days of the close of the claim, whether or not any payment was made to the claimant. With regard reports made pursuant to NRS 690B.045, copies must now be filed with the Division at the same time they are filed with the appropriate licensing board. To date, the Division has not formally specified a standard report form when making the reports required pursuant to NRS 690B.045 and 690B.050. As of March 31, 1986, all insurers when making a report, must utilize the modified "NAIC Medical Professional Liability Insurance Uniform Claims Report" as detailed in the "NAIC: Medical Malpractice Closed Claims Study 1975-1978" (September 1980). A copy of the report form is attached. DAVID A. GATES DAVID A. GATES Commissioner of Insurance DAG/ja Attachment O-3459 File one report for each defendant insured by filing insurer. Include claims based without payment. See reverse side for instructions. # Complete for all claims 1. Name of insurer ________________________ Claim file identification ________________________ 2. Date of injury ________________________ Date reported ________________________ Date reopened ________________________ 3. Insured's name ________________________ Age ______ City ________________________ State ______ Zip ______ 4. Profession or business ________________________ Specialty ________________________ Type of practice ________________________ 5. Board certification? ________________________ Foreign medical graduate? ________________________ Country ________________________ 6. Place where injury occurred ________________________ City ________________________ State ______ Zip ______ 7. Name of institution ________________________ 8. Injured person's name ________________________ Age ______ Sex ______ 9. Total defendants involved in claim ________________________ Derivative claim ________________________ 10. Amount of reserve for indemnity if still outstanding $ ________________________ 11. Amount of reserve for expense if still outstanding $ ________________________ # Complete for # Paid and Closed Claims Only 12. Plaintiff attorney's name ________________________ City ________________________ State ______ Zip ______ 13. Describe action which caused claim to be made ________________________ 14. Final diagnosis ________________________ 15. Operation, diagnostic or treatment procedure causing the injury ________________________ 16. Describe principal injury giving rise to the claim ________________________ Severity of injury ________________________ 17. Misadventures in procedures ________________________ Misadventures in diagnosis ________________________ 18. Others contributing to injury ________________________ Associated issues ________________________ Coverage ________________________ 19. Companion claim file identification 1. ________________________ 2. ________________________ 3. ________________________ # Complete for Paid and Closed Claims Only 20. Date of this payment or closure ________________________ Type settlement ________________________ 21. Disposition of trial ________________________ Binding arbitration? ________________________ 22. Indemnity paid by you on behalf of this defendant $ ________________________ 23. Other indemnity paid by or on behalf of this defendant $ ________________________ 24. Indemnity paid by all parties (for all defendants) $ ________________________ 25. Loss adjustment expense paid to all defense counsel $ ________________________ 26. All other allocated loss adjustment expense paid by you $ ________________________ 27. Injured person's incurred medical expense $ ________________________ 28. Injured person's anticipated future medical expense $ ________________________ 29. Injured person's incurred wage loss $ ________________________ 30. Injured person's anticipated wage loss $ ________________________ 31. Injured person's other expense $ ________________________ person responsible for report # NAIC MEDICAL PROFESSIONAL LIABILITY INSURANCE I FORM CLAIMS REPORT Report each claim closed on or after July 1, 2006. Submit a report for each defendant insured by filing insurer, including claims closed without payment. Complete all blocks on the form. If information is unknown, enter "UNK," if not applicable, enter "NA." When an item calls for a dollar amount and no amount is involved, enter 0 in the space after the $ sign. When you prepare a report on a reopened case on which a previous report has been made, mark "Previously Reported" at the top of the report. Record all amounts in whole dollars only, all dates as MM YY and all ages (on date of occurrence) as YY. | 1a. | Name of insurer | | | 1b. Claim file identification | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | 2a. | Date of injury | | | 2b. | Date reported to insurer | 2c. | Date reopened | | | 3a. | Insured's name | 3b. | Age | 3c. | City | 3d. | State | 3e. Zip | | 4a. | Profession or business (CODE) | | | 4b. | Specialty (CODE) | 4c. | Type of practice (CODE) | | | 5a. | Board certification (CODE) | | | 5b. | Foreign medical graduate? | 5c. | Country | | | 6a. | Place where injury occurred (CODE) | | | 6b. | City | 6c. | State | 6d. Zip | | 7a. | Name of institution (if injury occurred in institution) | | | 7b. | Location in institution (CODE) | 7c. | Hospital identification (Leave Blank) | | | 8a. | Injured person's name | | | | | 8b. | Age | 8c. Sex | | 9a. | Total defendants involved in claim | | | 9b. | Derivative claim (CODE) | | | | | 10. | Amount of reserve for indemnity if still outstanding $ | | | 11. | Amount of reserve for expense if still outstanding $ | | | | | 12a. | Plaintiff attorney's name | | | 12b. | City | 12c. | State | 12d. Zip | | 13. | Describe action which caused claim to be made | (Leave Blank) 14a. | | | | | | | | | | | | | | | | 14b. | | 14a. | Final diagnosis for which treatment was sought or rendered (patient's actual condition) | | | | | | | 15. | | 14b. | Describe misdiagnosis made, if any, of patient's actual condition | | | | | | | 15. | | 15. | Operation, diagnostic or treatment procedure causing the injury | | | | | | | 16a. | | 16a. | Describe principal injury giving rise to the claim | | | | | | | 16a. | | 16b. | Severity of injury (CODE) | | | | | | --- | --- | --- | --- | --- | --- | | 17a. | Misadventures in procedures (CODE) | | 17b. Misadventures in diagnosis (CODE) | | | | 18a. | Others contributing to injury (CODE) | | 18b. Associated issues (CODE) | 18c. Coverage (CODE) | | | 19 | Companion claim file identification | | | | | | | 1. | 2. | 3. | 4. | | | 20a. | Date of this payment or closure | | 20b. Claim disposition (CODE) | 20c. Settlement (CODE) | | | 21a. | Court (CODE) | | 21b. Binding arbitration (CODE) | 21c. Review panel (CODE) | | | 22. | Indemnity paid by you on behalf of this defendant | | | $ | | | 23. | Other indemnity paid by or on behalf of this defendant | | | $ | D ☐ E ☐ | | 24. | Indemnity paid by all parties (for all defendants) | | | $ | | | 25. | Loss adjustment expense paid to defense counsel | | | $ | | | 26. | All other allocated loss adjustment expense paid by you | | | $ | | | 27. | Injured person's incurred medical expense | | | $ | | | 28. | Injured person's anticipated future medical expense | | | $ | | | 29. | Injured person's incurred wage loss | | | $ | | | 30. | Injured person's anticipated wage loss | | | $ | | | 31. | Injured person's other expense | | | $ | | | 32. | Total amount allocated for future periodic payments (for all defendants) | | | $ | | Contact Person and Telephone Number Address Person Responsible for Report 10/77