Your Copic medical professional liability insurance policy includes “covered proceedings.” This covers protection for professional conduct or investigative matters. Here we explore in detail what that includes.
WHAT AREAS FALL UNDER COVERED PROCEEDINGS?
Disciplinary proceedings:
- State licensing authority (medical board) complaints alleging unprofessional conduct;
- Other proceedings initiated against the insured or receipt of written notification of a formal investigation against the insured by a federal or state governmental authority or a health care legal entity to review the competence, quality of care, or allegations of unprofessional conduct of health care professionals;
- Restriction, suspension, or revocation of clinical privileges.
Governmental investigations—A proceeding initiated against an insured or an insured has received written notification of a formal investigation brought by the state or federal government alleging:
- Illegal kickbacks or self-referral schemes;
- Unauthorized prescribing or distribution of controlled substances (e.g., an action brought by the DEA);
- Violation of the Emergency Medical Treatment and Active Labor Act (EMTALA);
Billing fraud and abuse investigations—A proceeding initiated against an insured or the insured has received written notification of a formal investigation by the state or federal government, or by a health care entity, alleging billing fraud and abuse.
Peer review proceedings—A peer or professional review action instituted by a hospital or other entity to review competence, professional conduct, and/or quality and appropriateness of patient care.
WHAT COSTS ARE COVERED?
Copic will pay defense costs incurred for a covered proceeding first reported while a policy is in effect*, up to the separate limits of liability shown on the Declaration Pages. “Defense costs” means all reasonable attorney fees and other fees, costs, and expenses attributable to the investigation, defense, or appeal of a claim or other legal or administrative dispute covered by your policy.
*Coverage not applicable to prior known acts.
WHAT ARE THE COMMON SCENARIOS WHERE INSUREDS UTILIZE THIS COVERAGE?
Most of the issues we see are related to when a provider’s care and treatment is called into question through situations such as complaints filed with the medical board and peer review inquiries.
WHAT ARE SOME KEY CONSIDERATIONS WITH THESE TYPES OF INCIDENTS?
Take all deadlines seriously—Often times, these incidents are tied to the provider having to respond or comply by a specific deadline. These deadlines should be viewed as firm dates and be taken very seriously as missing them can lead to negative professional consequences.
Keep a level head and don’t let your emotions get the best of you—Some of the situations, such as patient complaints, come across as personal attacks on your professional reputation. Don’t get caught up in your emotions and respond in a way that makes matters worse.
Notify Copic as soon as possible—Like all other incidents, the sooner you notify us, the better position we will be in to address the situation in a timely matter and get our experts involved. You may think you have time with a 30-day notice, but this time frame comes and goes very quickly.
Do not respond to any communications without first talking to Copic—While some issues can seem minor and straightforward, there may be unknown concerns and/or negative repercussions when you are not familiar with these situations. Always contact Copic for assistance before taking any action.
Utilize the attorney assistance that this coverage provides—Having legal assistance from attorneys is extremely valuable. Our attorneys have significant experience with these situations and know how to successfully manage them and the pitfalls to avoid. They offer trusted guidance through every step of the process.
Copic has a designated list of attorneys for covered proceedings—You must be assigned a Copic panel attorney prior to incurring costs for Copic’s covered proceedings coverage to apply. Retaining your own counsel prior to notifying Copic may result in this coverage not being applicable.
WHAT ARE THE LIMITS OF LIABILITY?
The policy limits for covered proceedings available to each insured for all covered proceedings matters initiated during a policy year (new policy or upon renewal date) is as follows:
- Each named insured listed on the Declaration Pages or added by endorsement will have a $25,000 annual aggregate policy limit.
- Professional corporations listed on the Declaration Pages or added by endorsement will share collectively in a $25,000 annual aggregate policy limit.
- $50,000 annual policy aggregate.
- This coverage is for defense costs only. Copic will not make any indemnity payments (e.g., fines or settlements) under your covered proceedings coverage.
Please note that the information in this article offers examples of potential coverage scenarios and that your policy terms outline the actual coverage you have in place. If you have any questions or would like more information, please contact your agent.
WHAT SHOULD I DO TO REPORT A COVERED PROCEEDINGS INCIDENT TO COPIC?
Report an incident by calling us at (800) 421-1834 or (720) 858-6395 and ask to speak with a Copic occurrence nurse specialist during business hours—Monday through Friday, 8am–5pm (Mountain time). Formal written notice addressed to an insured indicating commencement of a proceeding must be provided to Copic to trigger the coverage.
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Article originally published in 3Q24 Advantage Program Insight.
