Professional Liability Insurance (a) reports of claims (b) reports of terminations.

December 22, 1980 SUBJECT: INSURANCE Circular Letter No. 19 (1980) TO: ALL INSURERS AUTHORIZED TO WRITE PROFESSIONAL LIABILITY INSURANCE IN NEW YORK STATE RE: PROFESSIONAL LIABILITY INSURANCE a) REPORTS OF CLAIMS b) REPORTS ON TERMINATIONS Chapter 866 of the Laws of 1980 added a new Section 335-a to the Insurance Law, effective January 1, 1981, which requires the reporting to the Education Department of any disposition, whether by judgment, settlement or otherwise, of any claim made against an individual licensed under Title 8 of the Education Law, with the exception of physicians, physician's assistants and specialist's assistants, of incidents of professional malpractice or misconduct, where the claim was based upon fraud, incompetence or negligence. The Section also requires the reporting of cancellation of professional liability insurance, for reasons other than non-payment of premiums, of such licensed individuals. Every insurer engaged in the writing of professional liability insurance in this state shall file on the attached forms information on closed claims and terminations, in accordance with the enclosed instructions. Such reports shall be made to the Education Department. It is intended that claims be reported only by the primary carrier, in those cases where payment was made under the policy. However, an excess or umbrella carrier would be required to submit reports of claims if the primary carrier is not licensed in New York. Reports of claims and terminations on or after January 1, 1981 are due within 60 days following the date of disposition of any claim or termination of insurance. The Law provides that any report furnished in accordance with the provisions of Section 335-a shall be deemed a confidential communication and shall not be subject to inspection or disclosure in any manner except upon formal written request by a duly authorized public agency or pursuant to a judicial subpoena issued in a pending action or proceeding. The completed forms shall be mailed to: New York State Education Department Office of Professional Discipline 622 Third Avenue New York, NY 10017 Very truly yours, [SIGNATURE] Albert B. Lewis Superintendent of Insurance ATTACHMENT Professional Liability Insurance Claims Report (See Instruction Sheet Attached) 1. Name of Insurer____________________ 2. Claim file identification No.____________________ 3a. Date(s) of Occurrence(s)____________________ 3b. Date reported to Insurer____________________ 3c. Date reopened (if any)____________________ 3d. Date Occurrence reported to Insured____________________ 3e. Place(s) of Occurrence(s)____________________ 4a. Insured's Name____________________ 4b. Insured's Address____________________ 5a. Defendant's Name____________________ 5b. Defendant's Address____________________ 5c. Defendant's License No., if known____________________ 5d. Defendant's Date of Birth____________________ 6. Profession or business (CODE)____________________ 7a. Injured Person's Name____________________ 7b. Injured Person's Address____________________ 7c. Injured Person's Date of Birth____________________ 8. Plaintiff attorney's name, address & telephone No.____________________ 9a. Total number of defendants involved in claim____________________ 9b. Names and license No.s of other defendants, if known_____ _____________________________________________________________ _____________________________________________________________ 9c. Name and address of company insuring other defendants_____ _____________________________________________________________ _____________________________________________________________ 9d. Claim file No.s of additional defendants, if insured by your company__________________________________________________________ _____________________________________________________________ 10. Basis of claim:    a) Fraud__________ b) Incompetence__________   c) Negligence__________ d) Other (specify)____________________ 11. Describe action(s) which caused claim to be made. Include copy of complaint and copy of settlement agreement. 12. Associated issues (CODE)____________________ 13a. Claim Disposition (CODE)____________________ 13b. Settlement (CODE)____________________ 13c. Court (CODE)____________________ 14. Date of payment or closure____________________ 15. Indemnity paid by you on behalf of this defendant $_______ 16. Other indemnity paid by or on behalf of this defendant _____________________ Deductible [] Excess [] ______________________________ Contact Person's Name (Please Print) ____________________   _______________ Address ____________________ Person Responsible for Preparation of Report ________________ Telephone No. Complete all blocks on the form. Whenever information is not available or not applicable insert "N.A.". 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 the whole dollars only, all dates as MM YY. All fields are self-explanatory except as follows: 3a. Date of Alleged Occurrence, 3b. Date Reported and 3c. Date Reopened. Enter two digits each for month and year of occurrence and registration of incident as claim. Enter date in field provided on reopened cases. 5c. If insured defendant has a license number or operating certificate number, specify, if known. 6. Enter appropriate Code of insured's profession or business 01 Acupuncture 02 Architecture 03 Audiology 04 Certified Shorthand Reporting 05 Chiropractic 06 Dentist 07 Dental Hygienist 08 Landscape Architecture 09 Land Surveying 10 Massage 11 Registered Professional Nurse 12 Licensed Practical Nurse 13 Occupational Therapist 14 Occupational Therapy Assistant 15 Opthalmic Dispensing 16 Optometry 17 Pharmacy 18 Physical Therapy 19 Podiatry 20 Professional Engineering 21 Psychology 22 Certified Public Accountant 23 Public Accountant 24 Social Work 25 Speech Pathology 26 Veterinarian 27 Animal Health Technician 9a. Enter the Total Number of Defendants (persons and institutions other than John Does) Involved in Claim. Enter 1 if there is only one defendant. 10. Check item or items which are the basis of the claim. If d) Other, please specify. 11. Give a complete description of all actions and circumstances causing the claim. Include copy of complaint and settlement agreement. 12. Enter the appropriate Code(s) if one or more of the following factors were Associated Issues in the claim: 1) abandonment, 2) premature discharge from services, 3) false imprisonment, 4) lack or delay of consultation, 5) lack of supervision, 6) improper delegation of duty, 7) practice beyond scope, 8) breach of confidentiality, 9) failure to prevent an abnormal condition, 10) failure to accomplish intended result, 11) failure to conform with regulation or statutory rule, 12) lack of adequate facilities or equipment, 13) laboratory error, 14) pharmacy error, 15) failure to timely disclose, 16) failure to provide warning instructions, 17) lack of consent from proper person, 18) inadequate information for informed consent, 19) procedure exceeded consensual understanding, 20) unauthorized substitution or modification, 21) unwarranted treatment, 22) breach of contract, 23) guarantee, 24) assault and battery, 25) sterilization of equipment, 26) aseptic technique, 27) records, 28) billing and collection, 29) inter-professional relations, 30) codes, 31) failure to report fraudulent association, 32) failure to report disregard of specifications, 33) failure to provide prescription, 34) res ipsa loquitur, 35) vicarious liability, 36) statute of limitations, 37) punitive damages. 13a. Enter final method of Claim Disposition: 1) settled by parties, 2) disposed of by a court, 3) disposed of by binding arbitration. 13b. If settled by agreement of parties, enter appropriate Settlement Code: 1) before filing suit or demanding hearing, 2) before trial or hearing, 3) during trial or hearing, 4) after trial or hearing, but before judgment or decision (award), 5) after judgment or decision, but before appeal, 6) during appeal, 7) after appeal, 8) claim or suit abandoned, 9) during review panel or non-binding arbitration. 13c. Enter the appropriate Court Code: 0) no court proceedings, 1) directed verdict for plaintiff, 2) directed verdict for defendant, 3) judgment notwithstanding the verdict for the plaintiff, 4) judgment notwithstanding the verdict for the defendant, 5) judgment for the plaintiff, 6) judgment for the defendant, 7) for plaintiff after appeal, 8) for defendant after appeal, 9) all other. 16. Mark appropriate box if this amount was deductible paid by the insured or indemnity paid under an excess limits policy by another insurer. NEW YORK STATE INSURANCE DEPARTMENT PROFESSIONAL MEDICAL LIABILITY INSURANCE REPORT ON TERMINATION OTHER THAN NON-PAYMENT (See Instruction sheet attached) 1a. Name of Insurer____________________1b. Policy Number____________________ 2a. Type of Termination (CODE)____________________ 2b. Effective Date of Termination____________________ 3a. Insured's Name____________________ 3b. Insured's Address____________________ 3c. Insured's License Number____________________ 3d. Insured's Date of Birth________________________ 4a. Profession or business (CODE)________________________ 4b. Specialty (CODE)____________________ 5a. Board Certification (CODE)____________________ 5b. Foreign Medical Graduate?____________________ 5c. Country____________________ 6. Describe the specific reasons why this policy was terminated by the Company.________________________________________________________ ____________________________________________________________ ____________________ _________________ Contact Person and Person Responsible telephone No. (Please Print) for Report ____________________ Address Professional Liability Insurance Report On Termination Other Than Non-Payment (See Instruction Sheet Attached) 1. Name of Insurer____________________ 2. Policy No._________________________________ 3a. Type of Termination (CODE)______________________ 3b. Effective Date of Termination____________________ 4a. Insured's Name____________________ 4b. Insured's Address__________________________________ 4c. Insured's License No., if known___________________ 5. Profession or Business of Insured (CODE)____________________ 6. Describe the specific reason(s) why this policy was terminated by the Company____________________ ____________________ ____________________ __________________________________ Contact Person's Name (Please Print) Person Responsible for Preparation of Report ____________________ Address ____________________ Telephone No. Instruction Sheet For Report On Termination The following instructions apply to the items listed below: 3a. Enter CODE for type of termination: 1. cancellation by company (other than for non-payment of premiums) 2. non-renewal by company 5. Enter CODE of Profession or Business of Insured 01 Acupuncture 02 Architecture 03 Audiology 04 Certified Shorthand Reporting 05 Chiropractic 06 Dentist 07 Dental Hygienist 08 Landscape Architecture 09 Land Surveying 10 Massage 11 Registered Professional Nurse 12 Licensed Practical Nurse 13 Occupational Therapist 14 Occupational Therapist Assistant 15 Ophthalmic Dispensing 16 Optometry 17 Pharmacy 18 Physical Therapy 19 Podiatry 20 Professional Engineering 21 Psychology 22 Certified Public Accountant 23 Public Accountant 24 Social Work 25 Speech Pathology 26 Veterinarian 27 Animal Health Technician 6. Enter specific reason(s) for termination by the company. An acceptable specific reason shall not be an unsupported general statement such as "underwriting judgment".