Section 928.EXHIBIT B   Illinois Medical Professional Liability Insurance Uniform Claims Report – Reporting Instructions

 

To assist insurers and other reporting entities with electronic reporting, the Illinois Department of Financial and Professional Regulation-Division of Insurance (DOI) has created an electronic reporting application, which will be provided free of charge.  Reporting entities will choose one of the two processes depending on how they prefer to file.  One process will allow for data entry claim reporting and contain drop downs with choices.  The other process will allow for batch reporting.

 

As required by Section 155.19 of the Insurance Code [215 ILCS 5/155.19] and 50 Ill. Adm. Code 928:

 

1.         File all opened, closed, re-opened, and re-closed medical professional liability insurance claims and lawsuits, including any updates, with the DOI on a quarterly basis.  For closed claims, include claims closed without payment.  Insurance claim means a formal or written demand for compensation under a medical liability insurance policy relating to allegations of liability on the part of one or more providers for any act, error or omission in the rendering of, or failure to render, medical services for medically related injuries. Insurance claim includes any instance for which benefits or compensation are payable or eligible to be paid under any coverage under the policy. Lawsuit means a complaint filed in any court in this State alleging liability on the part of one or more providers for any act, error or omission in the rendering of, or failure to render, medical services for medically related injuries.

 

2.         File separate reports for each defendant you insure.  Each filing of a claim or lawsuit report shall be identified with a unique claim number.  If more than one defendant/insured is associated with an incident, a unique claim number is required for each defendant/insured.  If more than one claimant/injured party is associated with an incident, a unique claim number is required for each claimant/injured party.  When there are multiple associated claims/lawsuits, report companion claim numbers in the other claims information section.

 

3.         RESPONSES TO ALL FIELDS ARE REQUIRED.  For open claim reports, complete Insurer Information through Contact Person Information.  When updating reports, any information may be updated.  For closed claim reports, all fields are required.

 

4.         On the data entry process, drop downs are available for selecting codes for fields with an asterisk (*).

 

5.         On the data entry process, incomplete filings cannot be saved – i.e., if you quit a filing before you have completed all required fields, you will not be able to save that incomplete filing.

 

6.         Reports are due on a quarterly basis no later than 90 days after the quarter's end. 

 

NOTE:  If a company fails to submit accurate, timely, or complete reports, the Director may fine the company up to $1000 for each offense.  Each day during which a violation occurs constitutes a separate offense.

 

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Insurer Information

 

1a.       Insurer Name (not group name) (Maximum = 40 characters). 

 

1b.       Insurer 9-digit FEIN.  Entities without a Federal Employer Identification Number (FEIN), contact the DOI for assigned number.

 

Initial Claim Information

 

2a.       Claim ID.  For each open claim report, assign a distinguishing claim number sufficient to enable DOI to track a particular claim over a period of years.  On re-opened claims, use the same claim number as the original claim file that is being re-opened.

 

2b.       Coverage Code.*  Select the type of policy covering this claim. (1) Claims Made − Policy covers claim made during policy term regardless of when the incident occurred; (2) Prior Acts − Policy covers claim made during the policy term for events that occurred prior to the beginning of the policy term; (3) Occurrence − Policy covers claim that occurred during the policy term regardless of when the claim is presented; (4) Extended Reporting Period/Tail Coverage − Policy covers claim that occurred during the policy period but claim is made after the policy period ended.

 

2c.       Date of Principal or Alleged Injury.  (MM/DD/YYYY)

 

2d.       Date Incident First Reported to Insurer. (MM/DD/YYYY)  Date of alleged injury first reported to the insurer.

 

2e.       Date Claim Opened by Insurer. (MM/DD/YYYY)

 

2f.        Date Claim Re-Opened by Insurer. (MM/DD/YYYY)

 

2g.       Date of Closure of Original Claim.  (MM/DD/YYYY)

 

Insured Information

 

3a.       Profession or Business Code.* (1) Physician or Surgeon*; (2) Hospital; (3) Nurse*; (4) Nursing Home; (5) Dentist*; (6) Pharmacy; (7) Optometrist*; (8) Chiropractor*; (9) Podiatrist/Chiropodist*; (10) Clinic/Corporation; (11) Other* – Employee (Maximum = 25 characters). A code with an asterisk (*) requires a "Type of Practice Code" as well.

 

3b.       Type of Practice Code.* (1) Institutional, including Academic;  (2) Professional Corporation, Partnership, or Group;  (3) Self-Employed;  (4) Hospital;  (5) Nursing Home;  (6) All Other Employees;  (7) Intern or Resident.

 

3c.       Insured's Name, including suffix such as MD, DO, etc.

 

3d.       Insured's Illinois License Number.  If unavailable, enter insured's Social Security Number. Enter FEIN for clinics and corporations.

 

3e.       Insured's Date of Birth (MM/DD/YYYY).  Not applicable to institution, group, or partnership.

 

3f.        Five-digit ISO Specialty Code from Current ISO Common Statistical Base Classifications. Check annually with ISO for possible changes to specialty codes.  Specialty code must be tied to the year the alleged injury occurred.

 

3g.       Board Certified?*  Y or N. 

If Board Certified is answered with a "Y", Name of Board is required (Maximum = 25 characters).

 

3h.       County of Insured's Principal Place of Practice for Rating Purposes.

 

Place of Injury Information

 

4a.       Place Where Alleged Injury Occurred Code.*  Enter only one. (1) Hospital Inpatient Facility*; (2) Emergency Room; (3) Hospital Outpatient Facility*; (4) Nursing Home*; (5) Physician's Office; (6) Patient's Home; (7) Other Outpatient Facility, including Clinics*; (X) Other* – describe place (Maximum = 25 characters).

A code with an asterisk (*) requires a "Location Within Institution Code" as well.

 

4b.       Location Within Institution Code.*  (1) Patient's Room; (2) Labor/Delivery Room; (3) Operating Suite; (4) Recovery Room; (5) Critical Care Unit; (6) Special Procedure Room; (7) Nursery; (8) Radiology; (9) Physical Therapy Department; (X) Other – describe (Maximum = 25 characters).

 

4c.       Name of Institution. (Maximum = 25 characters)

 

4d.       County Where Alleged Injury Occurred.

 

Injured Person Information

 

5a.       Injured Person's Name.

 

5b.       Injured Person's Gender.  M    F

 

5c.       Injured Person's Age Category.

 

5d.       Injured Person's Social Security Number (for cross-tracking purposes only; information is kept confidential).

 

5e.       County.

 

Other Claim Information

 

6a.       Total Number of Defendants.   Enter total number of persons or corporations that you insure that are involved in this claim. 

 

6b.       Companion Claim Number(s).  Enter claim identification numbers for all claims against other defendants you insure that are involved in this claim.  Space is limited to five separate claim numbers (Maximum = 35 characters each).

 

Contact Person Information

 

7a.       Name of Person Responsible for Preparing this Report.

 

7b.       Title of Person Responsible for Preparing this Report.

 

7c.       Contact Person Name (if different than Name of Person Responsible for Preparing this Report).

 

7d.       Contact Person Telephone Number.

 

7e.       Contact Person Email Address.

 

Plaintiff Attorney Information

 

8a.       Plaintiff Attorney's Name or Name of Law Firm.

 

8b.       Plaintiff Attorney's Office City.

 

8c.       Plaintiff's Attorney's Office State.*

 

Claim Data Information

 

9a.       Nature and Substance of Claim.  Give complete description of all actions and circumstances causing the claim, including allegations made by claimant.  (Maximum = 250 characters)

 

9b.       Act or Omission Codes Related to Claim.*  Enter as many codes as needed.  Use DOI 3-digit codes listed below.  (1) Diagnosis Related;  (2) Anesthesia Related;  (3) Surgery Related;  (4) Medication Related;  (5) Intravenous and Blood Products Related;  (6) Obstetrics Related;  (7) Treatment Related;  (8) Monitoring Related;  (9) Biomedical Equipment/Product Medication Related;  (10) Miscellaneous Related. 

 

DOI 3-digit Act or Omission Code choices:

 

Diagnosis-Related         010 – Failure to Diagnose (e.g., concluding that patient has no disease or condition worthy of follow-up or observation)

020 – Wrong Diagnosis or Misdiagnosis (e.g., original diagnosis is incorrect)

030 – Improper Performance of Test

040 – Unnecessary Diagnostic Test

050 – Delay in Diagnosis

060 – Failure to Obtain Consent/Lack of Informed Consent

070 – Diagnosis Related – Not Otherwise Classified

 

Anesthesia-Related       110 – Failure to Complete Patient Assessment

120 – Failure to Monitor

130 – Failure to Test Equipment

140 – Improper Choice of Anesthesia Agent or Equipment

150 – Improper Technique/Induction

160 – Improper Equipment Use

170 – Improper Intubation

180 – Improper Positioning

185 – Failure to Obtain Consent/Lack of Informed Consent

190 – Anesthesia Related – Not Otherwise Classified

 

Surgery-Related            210 – Failure to Perform Surgery

220 – Improper Positioning

230 – Retained Foreign Body

240 – Wrong Body Part

250 – Improper Performance of Surgery

260 – Unnecessary Surgery

270 – Delay in Surgery

280 – Improper Management of Surgical Patient

285 – Failure to Obtain Consent/Lack of Informed Consent

290 – Surgery Related – Not Otherwise Classified

 

Medication-Related      305 – Failure to Order Appropriate Medication

310 – Wrong Medication Ordered

315 – Wrong Dosage Ordered of Correct Medication

320 – Failure to Instruct on Medication

325 – Improper Management of Medication Regimen

330 – Failure to Obtain Consent/Lack of Informed Consent

340 – Medication Error – Not Otherwise Classified

350 – Failure to Medicate

355 – Wrong Medication Administered

360 – Wrong Dosage Administered

365 – Wrong Patient

370 – Wrong Route

380 – Improper Technique/Induction

390 – Medication Administration Related – Not Otherwise Classified

 

Intravenous &                410 − Failure to Monitor

Blood Products-           420 – Wrong Solution

Related                         430– Improper Performance

440 – I.V. Related – Not Otherwise Classified

450 – Failure to Ensure Contamination Free

460 – Wrong Type

470 – Improper Administration

480 – Failure to Obtain Consent/Lack of Informed Consent

490 – Blood Product Related – Not Otherwise Classified

 

Obstetrics-Related       505 – Failure to Manage Pregnancy

510 – Improper Choice of Delivery Method

520 – Improperly Performed Vaginal Delivery

530 – Improperly Performed C-Section

540 – Delay in Delivery (Induction or Surgery)

550 – Failure to Obtain Consent/Lack of Informed Consent

555 – Improperly Managed Labor – Not Otherwise Classified

560 – Delay in Treatment of Fetal Distress (i.e., identified but treated in untimely manner)

570 – Retained Foreign Body/Vaginal/Uterine

575 – Abandonment

580 – Wrongful Life/Birth

590 – Obstetrics Related – Not Otherwise Classified

 

Treatment-Related        610 – Failure to Treat

620 – Wrong Treatment/Procedure Performed

630 – Failure to Instruct Patient on Self-Care

640 – Improper Performance of Treatment/Practice

650 – Improper Management of Course of Treatment

660 – Unnecessary Treatment

665 – Delay in Treatment

670 – Premature End of Treatment (Also Abandonment)

675 – Failure to Supervise Treatment/Procedure

680 – Failure to Obtain Consent/Lack of Informed Consent

685 – Failure to Refer or Seek Consultation

690 – Treatment Related – Not Otherwise Classified

 

Monitoring-Related       710 – Failure to Monitor

720 – Failure to Respond to Patient

730 – Failure to Report on Patient Condition

790 – Monitoring Related – Not Otherwise Classified

 

Biomedical                    810 − Failure to Inspect/Monitor

Equipment/                    820 − Improper Maintenance

Product-Related            830 – Improper Use

840 – Failure to Respond to Warning

850 – Failure to Instruct Patient on Use of Equipment/Product

860 – Malfunction/Failure

890 – Biomedical Equipment/Product-Related – Not Otherwise Classified

 

Miscellaneous-              920 − Failure to Protect Third Parties (e.g., failure to warn/protect

Related                                   from violent patient behavior)

930 – Breach of Confidentiality/Privacy

940 – Failure to Maintain Appropriate Infection Control

950 – Failure to Follow Institutional Policy or Procedure

960 – Other (Provide Detailed Description) 

990 – Failure to Review Providing Performance

 

9c.       Severity of Injury Code. Select only one − Select code for principal injury if several injuries are involved.*

1)         Emotional Only (e.g., fright, no physical damage)

Temporary:       2)         Insignificant (e.g., lacerations, contusions, minor scars,

rash; no delay)

3)         Minor (e.g., infections, misset fracture, fall in hospital; recovery delayed)

4)         Major (e.g., burns, surgical material left, drug side effect, brain damage; recovery delayed)

Permanent:       5)         Minor (e.g., loss of fingers, loss or damage to organs;

includes non-disabling injuries)

6)         Significant (e.g., deafness, loss of limb, loss of eye, loss of one kidney or lung)

7)         Major (e.g., paraplegia, blindness, loss of two limbs, brain damage)

8)         Grave (e.g., quadriplegia, severe brain damage, lifelong care or fatal prognosis)

9)         Death

 

9d.       Date of Closure of Claim. (MM/DD/YYYY)

 

9e.       Claim Disposition Code.*  Enter code representing the final disposition of the claim. (1) Settled by Parties*; (2) Disposed of by a Court**; (3) Disposed of by Binding Arbitration***; (4) Suit Abandoned****; (5) Claim Abandoned.

A code with an (*) requires a "Settlement Code" as well.

A code with an (**) requires "Court Information" to be completed as well.

A code with an (***) requires a "Binding Arbitration Code" as well.

A code with an (****) requires a "County of Circuit Court" and "Docket Number" as well.

 

9f.        Settlement Code.*  (1) Before Filing Suit or Demanding Arbitration 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) As a result of Review Panel or Non-Binding Arbitration**;  (9) As a Result of Mediation;  (10) As a Result of High/Low Settlement***.

A code with an (**) requires a "Review Panel or Non-Binding Arbitration Code" as well.

A code with an (***) requires all applicable "Court Information" except "Court Code".

 

9g.       Review Panel or Non-Binding Arbitration Code.*  (1) Finding for Plaintiff;  (2) Finding for Defendant.

 

9h.       Binding Arbitration Code*  (1) Award for Plaintiff;  (2) Award for Defendant.

 

Court Information

 

10a.     Court Code.* (1) Directed Verdict for Plaintiff;  (2) Directed Verdict for Defendant;  (3) Judgment Notwithstanding Verdict for Plaintiff (judgment for defendant);  (4) Judgment Notwithstanding Verdict for Defendant (judgment for plaintiff);  (5) Judgment for Plaintiff;  (6) Judgment for Defendant;  (7) Decision for Plaintiff on Appeal;  (8) Decision for Defendant on Appeal;  (9) Voluntary Dismissal;  (10) Involuntary Dismissal;  (11) All Other Actions.

 

10b.     County of Circuit Court.

 

10c.     Docket Number.

 

10d.     Amount Awarded by Circuit Court. (whole dollar amounts only)

 

10e.     Date of Award. (MM/DD/YYYY)

 

10f.      Was the Circuit Court decision appealed?  Y or N

 If "Y", Describe the Result of the Appeal. (Maximum = 25 characters)

 

10g.     Describe any Other Post Trial Motions. (Maximum = 25 characters)

 

10h.     Economic Damages.  Amount of economic damages awarded by the court.  This amount plus 10i. Non-economic Damages must equal 10d. Amount Awarded by Circuit Court. (whole dollar amounts only)

 

10i.      Non-economic Damages.  Amount of economic damages awarded by the court.  This amount plus 10h. Economic Damages must equal 10d. Amount Awarded by Circuit Court. (whole dollar amounts only)

 

Claim Payment Information

 

11a.     Total Direct Indemnity Paid/Payable by You Under this Policy on Behalf of this Insured/Defendant.  Amount reported here shall be less than or equal to 10d. Amount Awarded by Circuit Court, if 10d. contains an amount greater than 0. (whole dollar amounts only)

 

11b.     Economic Damages. If 9e. Claim Disposition Code is (2) Disposed of by a Court, enter the amount that was paid/payable by you for economic damages, as indicated by the court award.  This amount plus 11c. Non-Economic Damages must equal amount reported in 11a. Total Direct Indemnity Paid/Payable by You Under this Policy on Behalf of this Insured/Defendant. (whole dollar amounts only)

 

11c.     Non-Economic Damages.  If 9e. Claim Disposition Code is (2) Disposed of by a Court, enter amount that was paid/payable by you for non-economic damages, as indicated by the court award.  This amount plus 11b. Economic Damages must equal amount reported in 11a. Total Direct Indemnity Paid/Payable by You Under this Policy on Behalf of this Insured/Defendant. (whole dollar amounts only)

 

11d.     Direct Loss Adjustment Expense Paid/Payable by You under this Policy to Defense Counsel. (whole dollar amounts only)

 

11e.     All Other Allocated Loss Adjustment Expenses Paid/Payable by You for this Insured/Defendant for this claim, including filing fees, telephone charges, photocopy fees, expenses of defense counsel, etc. (whole dollar amounts only)

 

11f.      Direct Indemnity Paid/Payable by You Under All Policies for this Insured/Defendant. (whole dollar amounts only)

 

11g.     Other Indemnity Paid by or on Behalf of this Insured/Defendant. (whole dollar amounts only)

D)        Deductible(s) paid by insured/defendant for this claim under this policy;

E)         Indemnity paid under any excess limits policy issued by you;

R)        Amount paid by insured/defendant under self-insured retention;

S)         Amount you paid above any stop loss limit.

 

11h.     Claimed Medical Expense.  Amount of medical expense claimed by the plaintiff/injured party. (whole dollar amounts only)

 

11i.      Claimed Wage Loss.  Amount of wage loss claimed by the plaintiff/injured party. (whole dollar amounts only)"

 

(Source:  Amended at 30 Ill. Reg. 19288, effective December 4, 2006)