Medical Malpractice Settlement Report

JOB MILLER Governor STATE OF NEVADA ROSE McKINNEY-JAMES Director ALICE A. MOLASKY, ESQ. Commissioner of Insurance # DEPARTMENT OF BUSINESS AND INDUSTRY # DIVISION OF INSURANCE Capitol Complex 1665 Hot Springs Road, No. 152 Carson City, Nevada 89710 (702) 687-4270 BULLETIN 95-001 October 16, 1995 # MEDICAL MALPRACTICE SETTLEMENT REPORT NRS 690.045 requires insurers which provide liability insurance for a "practitioner" licensed pursuant to chapters 630 to 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. Additionally, NRS 690B.050 requires a report to the Division of Insurance (Division) where the insured is a doctor of medicine licensed pursuant to chapter 630 of NRS. The report is required if a liability policy covering acts of professional malpractice exists, and if a settlement or award is made, or if a judgment is rendered. 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. The reports made pursuant to NRS 690B.050 must be filed with the Division at the same time they are filed with the appropriate licensing board. # MEDICAL MALPRACTICE CLOSED CLAIMS REPORT The Division has revised the report form required pursuant to NRS 690B.045 and NRS 690B.050. The new form is the NEVADA MEDICAL PROFESSIONAL LIABILITY REPORT FORM and is effective for claims closed on and after Novemeber 1, 1995. For any questions concerning this report, please contact the property/casualty section of the Division at (702) 687-7682. BULLETIN 86-002 is withdrawn. F:\s\w\Bull95.001 ALICE A. MOLASKY, ESQ. Commissioner of Insurance L-5 # NEVADA MEDICAL PROFESSIONAL LIABILITY REPORT FORM Report each claim closed on or after November 1, 1995. Submit a report for each defendant insured by filing insurer, including claims closed without payment. Complete all blocks on the form. If information is 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. Record all amounts in whole dollars only, all dates as MM YY and all ages (on the date of occurrence) as YY. All sections of this form must be completed. If any sections are left incomplete, this form will be returned to you with a request to include the appropriate information. 1. Name of Insurer: 2. Claim Number: 3a. Date of Injury: 3b. Date Reported to Insurer: 3c. Date of Closure: 4a. Insured's Name: 4b. Insured's Address: 5a. Board Certification: Yes ( ) No ( ) 5b. Specialty Code per ISO: 5c. Description: 5d. Foreign Medical School Graduate: Yes ( ) No ( ) 6a. Claimant's Name: 6b. Age: 6c. Sex: 6d. Claimant's Address: 7. Description of the Acts or Omissions and Injuries or Illnesses upon which the Claim or Action was Based: 8a. Name of Institution (IF injury occurred in Institution): 8b. ISO Code: 8c. City: 8d. County: 9a. Co-Defendant Yes ( ) No ( ) 9b. If Yes, how many: 9c. Name of Co-Defendant(s) Insurer: 9d. Co-Defendant(s) Claim file Identification: 10a. Medical Dental Screening Panel Case Number: 10b. Medical Dental Screening Panel findings: (Check Appropriate Findings): 1. ☐ No Malpractice 2. ☐ Malpractice and Injury 3. ☐ Unable to decide 4. ☐ Settled before Panel met 5. ☐ Dismissed by Panel 11a. Court Case Filed: Yes ( ) No ( ) 11b. If Yes, Filed in City & County of: 12. Case Value from Settlement Judge (if applicable): 13a. Binding Arbitration: Yes ( ) No ( ) 13b. Verdict Amount: 14a. Structured Settlement: Yes ( ) No ( ) 14b. Settlement Amount: 14c. Date of First Payment: 15. Amount of Indemnity Reserve if Still Outstanding: 16. Amount of Loss Adjustment Expense Reserve if Still Outstanding: 17. Indemnity Paid by You on Behalf of Defendant: 18. Total Allocated Loss Adjustment Paid by You on Behalf of Defendant: Contact Person and Telephone Number Name of Person Responsible for Report Signature of Person Responsible for Report Address CLOSED CLAIM REPORT, Edition: 11/95