Health Care Liability Act 2001 INSURANCE REGULATION ORDER 2001 - Made under the Health Care Liability Act 2001 - As at 25 July 2003 - Reg 988 of 2001 TABLE OF PROVISIONS TABLE OF PROVISIONS 1. Definitions PART 1 - GENERAL REQUIREMENTS 1. Compliance with Order 2. Conditions as to range and differentiation of insurance 3. Premium filing 4. Certificate of approved insurance PART 2 - DECISIONS CONCERNING INDIVIDUAL COVER Division 1 1. Preliminary Division 2 - Existing policy holders 2. Decisions concerning individual cover 3. Proper notice and explanation 4. Opportunity for consideration by Medical Board at practitioner’s election Division 3 - New applicants 5. Decisions concerning individual cover PART 3 - PREMIUM MODERATION FOR OBSTETRICS AND NEUROSURGERY 1. Definitions 2. Premium relativities for obstetrics and neurosurgery 3. (Repealed) PART 4 - CLAIMS HANDLING 1. Claims handling generally 2. Early evaluation of claims PART 5 - DATA COLLECTION AND REPORTING 1. 2. 3. ____ Schedule 2 (Repealed) SCHEDULE 3 SCHEDULE 4 SCHEDULE 5 INSURANCE REGULATION ORDER 2001 - REG 1 Definitions 1 Definitions In this order: "Act" means the Health Care Liability Act 2001. "adverse decision" means a decision to offer or provide professional indemnity insurance to a medical practitioner on terms and conditions that are less favourable to the medical practitioner than those applying to all other, or a majority of, policy holders of the same premium category. "annual premium" means the total amount of premium which would be paid for a one year period of coverage regardless of whether the entire premium is paid at one time or in instalments, or whether the premium which is actually paid in any particular case is pro rated for a lesser period of coverage. "approved insurance" means approved professional indemnity insurance as defined in the Act. "authorised insurer" means a person that has an authority to carry on insurance business under the Commonwealth Insurance Act 1973 and includes a Lloyd’s underwriter. "category of insurance" means a category of insurance specified under clause 2 of the Insurance Approval Order dated 4 December 2001. "category of specialty" means (i) general practice, or (ii) specialist practice in a specific area of medicine. "Director-General" means the Director-General of the NSW Department of Health established under the Health Administration Act 1982. "discretionary mutual organisation" means a mutual organisation: (i) which does not directly engage in or carry on insurance or reinsurance business, and (ii) the membership of which entitles a person, who has a liability or potential liability resulting from a risk or contingency previously specified by the organisation as one which it may indemnify members against, to apply for a grant of assistance to meet all or part of the costs associated with such liability or potential liability, but does not provide the person with a contractual right to receive a compensatory payment, and (iii) which, after due consideration of an application for assistance from a member who has a liability or potential liability resulting from a risk or contingency previously specified by the organisation as one which it may indemnify members against, has an absolute discretion whether to indemnify the member. "general practice" means the practice of medicine not involving specialist qualifications recognised as such under the Health Insurance Act. "health care" is as defined in the Act. "health care claim" means a claim for damages or other compensation, whether by verbal or written demand or the commencement of legal proceedings, against a medical practitioner (or his or her practice company) in respect of an injury (including wrongful birth) or death caused wholly or partly by the fault or alleged fault of the practitioner in providing or failing to provide health care. "Health Insurance Act" means the Health Insurance Act 1973 (Commonwealth). "insurance approval order" is as defined in the Act. "Insurance Contracts Act" means the Insurance Contracts Act 1984 (Commonwealth). "insurer" includes a discretionary mutual organisation. "medical practitioner" is as defined in the Medical Practice Act 1992. "mutual organisation" means a not-for-profit organisation formed by a group of persons or companies exposed to some risk or contingency common to the group who are prepared to share financially with each other, on a proportionate basis, the cost of any loss incurred by an individual member of the group, if the contingency occurs to the member. "non-exempt medical practitioner" means a medical practitioner who is not exempt under the Act or regulations from the requirement to be covered by approved insurance in respect of all their medical practice. "policy" includes a discretionary indemnity arrangement. "policyholder" includes a member of a discretionary mutual organisation. "premium" includes subscription or other payment for professional indemnity insurance. "premium category" means a category of specialty combined with any other form of categorisation utilised by an insurer for the purposes of premium setting for non-exempt medical practitioners "record of claims history" means a record of the number of health care claims, or incidents that may give rise to health care claims, notified to the insurer, including date of notification of each claim, date and brief description of each relevant incident and the compensation range within which the claim fell, or is estimated to fall, as follows: (i) < $50 000 (ii) $50 000–< $100 000 (iii) $100 000–< $250 000 (iv) $250 000–< $500 000 (v) $500 000–< $1 million (vi) $1 million + "relevant notification date" is the date, being either 1 January or 1 July in each year, which the insurer has elected as the date by which it is to comply with any annual notification requirements of an insurance approval order (or in the absence of such requirements a date approved by the Director-General in respect of a particular insurer). "significant adverse decision" means an adverse decision which: (i) requires a practitioner, as a condition of approved insurance, to pay a deductible of an amount which is $20,000 or more in respect of any claim, or (ii) requires a practitioner to pay a premium for approved insurance which is over 50% higher than the premium charged by the insurer for all other, or a majority of, medical practitioners of the same premium category. "specialist practice" means the practice of medicine involving specialist qualifications recognised as such under the Health Insurance Act. INSURANCE REGULATION ORDER 2001 - REG 1 Compliance with Order 1 Compliance with Order (1) An insurer that provides approved insurance to non-exempt medical practitioners must comply with the requirements of this order. (2) However nothing in this order is to be taken to alter the discretionary nature of indemnity offered by a discretionary mutual organisation. INSURANCE REGULATION ORDER 2001 - REG 2 Conditions as to range and differentiation of insurance 2 Conditions as to range and differentiation of insurance (1) An insurer is not to offer or provide approved insurance on terms and conditions: (a) which differ depending upon whether or not patients of a medical practitioner have private health insurance, (b) which differ depending upon whether patients of a medical practitioner are, or will be, liable to pay for medical services provided in the course of practice. (2) However these requirements do not prevent an insurer from offering or providing approved insurance at premiums which differ depending upon whether or not medical practitioners are exempt in respect of part or all of their professional practice from the requirement to be covered by approved insurance. (3) In respect of any category of insurance offered to new applicants, an insurer must offer approved insurance for all categories of specialty in a manner that complies with sub-clause 2 (4). (4) Market conduct an insurer is not to engage in pricing, underwriting or other commercial conduct which, it can reasonably be inferred, is directed at acquiring and maintaining a market share of non-exempt medical practitioners in which those categories of specialty which involve surgery or obstetrics are under-represented, having regard to: (a) the overall numbers of non-exempt medical practitioners in NSW in each category of specialty, and (b) the insurer’s individual market share of practitioners in each such category. INSURANCE REGULATION ORDER 2001 - REG 3 Premium filing 3 Premium filing (1) An insurer must comply with the following: (a) within 28 days of the date of commencement of this order, or such longer period as the Director-General may approve in any particular case, the insurer must notify the Director-General of the number of medical practitioners covered by professional indemnity insurance by the insurer as at 31 December 2001, and (b) within 28 days of the date of commencement of this order and subsequently by the relevant notification date in each year the insurer must notify the Director-General of: (i) the premium categories the insurer offers to cover by approved insurance as at 1 January 2002 or as at the relevant notification date, as the case may be, and (iii) the annual premium for each such premium category as at 1 January 2002 or as at the relevant notification date, as the case may be, (c) the insurer is to notify the Director-General, in writing, of any variation to premium categories offered, or any annual premiums for relevant premium categories notified under paragraph (b), within 28 days of such variation being made, together with details of the variation, (d) within 42 days of the relevant notification date, the insurer must notify the Director-General of the number of non-exempt medical practitioners underwritten by the insurer in each premium category as at the relevant notification date. (2) An insurer may elect to provide the information notified under sub-clause (1) on a commercial-in-confidence basis. INSURANCE REGULATION ORDER 2001 - REG 4 Certificate of approved insurance 4 Certificate of approved insurance (1) On and from 1 January 2002, within one month of receipt of payment for a new policy of approved insurance from a medical practitioner or for a renewal of such insurance, the insurer must provide to the medical practitioner a certificate in true and accurate form specifying the following: (a) that the medical practitioner is covered by approved insurance provided by the insurer, (b) the period of cover of such insurance, and (c) that the certificate is provided in accordance with an insurance regulation order made under the Act. (2) An insurer must ensure that each medical practitioner who is covered by approved insurance has been issued with a certificate in the same terms as the certificate required under sub-clause (1) by 31 May 2002. INSURANCE REGULATION ORDER 2001 - REG 1 Preliminary 1 Preliminary (1) For the purposes of this Part: a refusal to provide approved insurance includes: (i) not accepting an offer to enter into a contract or discretionary indemnity arrangement for such insurance, or (ii) cancelling a contract or terminating a discretionary indemnity arrangement for such insurance, or (iii) not renewing such insurance, or (iv) not offering such insurance. (2) Copy of requirements of this Part to be provided to practitioners An insurer must, upon request, provide an applicant for approved insurance or an existing policy holder with a copy of the conditions the insurer must comply with under this Part. (3) Provision of claims history upon request by practitioner An insurer, within ten working days of receiving a written request from a medical practitioner who: (a) is covered by approved insurance by the insurer, or (b) within the immediately preceding six years has been covered by professional indemnity insurance by the insurer, must provide to the medical practitioner his or her record of claims history for whichever is the lesser of the following periods: (i) the most recent six year period of the insurance cover, or (ii) the total period that the insurer has provided professional indemnity insurance to the practitioner. INSURANCE REGULATION ORDER 2001 - REG 2 Decisions concerning individual cover 2 Decisions concerning individual cover (1) During the period that an adverse decision applies to an existing policy holder, access to risk management activities, which have the purpose of assisting the policyholder to reduce his or her individual claims risk, are to be offered or facilitated by the insurer. (2) Withdrawal of cover An insurer must not refuse to provide approved insurance to an existing policy holder: (a) who has been registered as a medical practitioner for a period of less than three years and who has not previously had his or her name removed from the medical register following disciplinary proceedings, or (b) who has held specialist qualifications recognised under the Health Insurance Act for a period of less than three years and who has not previously had his or her name removed from the medical register following disciplinary proceedings, or (c) in the case of a medical practitioner to whom paragraph (a) or (b) does not apply, unless the medical practitioner has an incident and claims history the insurer considers warrants such a decision. (3) Sub-clause (2) does not apply where an insurer refuses to provide approved insurance: (a) for a reason which is of a similar kind to a reason that enables the cancellation of a contract of general insurance, or the avoidance of a claim or policy, in accordance with the relevant provisions of the Insurance Contracts Act, or (b) for a reason which relates to a breach or non- observance by the medical practitioner of the conditions of the relevant membership arrangements or the terms and conditions of the relevant insurance policy, or the non- payment of the relevant premium or membership fees, or (c) because the insurer ceases to engage in the business of providing professional indemnity insurance to non-exempt medical practitioners. (4) For the purposes of this clause a decision by an insurer to charge a medical practitioner a premium which is at least twice the premium charged by the insurer to all, or a majority of, medical practitioners of the same premium category is taken to be a decision to refuse to provide approved insurance. INSURANCE REGULATION ORDER 2001 - REG 3 Proper notice and explanation 3 Proper notice and explanation (1) Subject to clause 4 of this Part, an insurer must not (whether upon renewal or otherwise), because of the incident and claims history of an existing policy holder, make an adverse decision in respect of the approved insurance of the policy holder or a decision to refuse to provide approved insurance to the policy holder, unless the insurer: (a) in the case of any adverse decision, has given the policy holder 28 days’ written notice prior to the decision taking effect, or (b) in the case of a decision to refuse to provide professional indemnity insurance, has given the policy holder two months’ written notice prior to the decision taking effect together with a copy of the claims history specified at clause 1 (3) of this Part. (2) Prior to giving such notice under sub-clause (1) (a) the insurer must: (a) give the relevant medical practitioner a reasonable opportunity to discuss the proposed decision and the reasons for it with the insurer, and (b) take into account any matters raised by the medical practitioner in the course of those discussions. (3) If requested by the relevant medical practitioner, the insurer must provide to him or her a written explanation of the reasons for its refusal to provide approved insurance. (4) This clause does not apply where an insurer upon renewal of professional indemnity insurance continues to give effect to an adverse decision made prior to the insurance being renewed. (5) For the purposes of this clause a decision by an insurer to charge a medical practitioner a premium which is at least twice the premium charged by the insurer to all, or a majority of, medical practitioners of the same premium category is taken to be a decision to refuse to provide approved insurance. INSURANCE REGULATION ORDER 2001 - REG 4 Opportunity for consideration by Medical Board at practitioner’s election 4 Opportunity for consideration by Medical Board at practitioner’s election (1) This clause applies to a refusal to provide approved insurance because of the incident and claims history of an existing policyholder. (2) For the purposes of this clause a decision by an insurer to charge a medical practitioner a premium which is at least twice the premium charged by the insurer to all, or a majority of, medical practitioners of the same premium category, is taken to be a decision to refuse to provide approved insurance. (3) If within 28 days of receiving notice of a decision to refuse to provide approved insurance in respect of an existing policyholder, the policyholder: (a) authorises the insurer, in writing, to notify the Medical Board of any matter which forms the basis of the decision and to provide to the Medical Board information and documentation relevant to such matter, and (b) authorises the Medical Board, in writing, to provide to the insurer a copy of its advice to the practitioner as to the outcome of any such notification, if made, and in those cases where the Medical Board refers a matter to an Impaired Registrants Panel or for assessment under Part 5A of the Medical Practice Act 1992, copies of any relevant decisions, reports and recommendations arising from the referral, an insurer is to forward the relevant information to the Medical Board. (4) If an insurer is authorised to forward information to the Medical Board under sub-clause (3), an insurer is not to give effect to the decision to refuse to provide professional indemnity insurance pending whichever of the following occurs first: (a) the expiration of a period of three months from the date of forwarding the relevant information pursuant to sub-clause (3), or (b) receipt and consideration by the insurer of copies of the information referred to under sub-clause (3) (b). (5) If such matters are the subject of a referral to an Impaired Registrants Panel or form the basis of a referral for assessment under Part 5A of the Medical Practice Act 1992, the insurer is to: (a) review its decision (whether or not it has already given effect to that decision) following receipt and consideration by the insurer of any reports and recommendations arising from the referral, and of advice on any action taken by the Medical Board consequent upon those reports and recommendations, and (b) take reasonable steps to advise the relevant practitioner of the outcome of that review. (6) Nothing in this clause prevents an insurer from charging a premium of an amount that does not constitute a refusal to provide approved insurance under sub-clause (2) pending receipt of the Medical Board’s advice or the expiration of three months, whichever first occurs, in accordance with sub-clause (3). INSURANCE REGULATION ORDER 2001 - REG 5 Decisions concerning individual cover 5 Decisions concerning individual cover (1) In this clause a refusal of an application for approved insurance includes a decision to not accept an offer to enter into a contract or discretionary indemnity arrangement for such insurance. (2) Newly qualified practitioners An insurer must not make a significant adverse decision in respect of an application for approved insurance from a medical practitioner who has not previously held professional indemnity insurance with that insurer: (a) if the applicant has been registered as a medical practitioner for a period of less than three years and has not previously had his or her name removed from the medical register following disciplinary proceedings, or (b) if the applicant has held specialist qualifications recognised under the Health Insurance Act for a period of less than three years and has not previously had his or her name removed from the medical register following disciplinary proceedings. (3) Refusal of cover Before giving effect to a decision to refuse an application for approved insurance from a medical practitioner an insurer must give the medical practitioner a reasonable opportunity to discuss the proposed decision and the reasons for it with the insurer. (4) If requested by a medical practitioner whose application for approved insurance is refused, the relevant insurer must provide him or her with a written explanation of the reasons for its refusal. INSURANCE REGULATION ORDER 2001 - REG 1 Definitions 1 Definitions In this Part and Schedule 1: "maximum premium category" means the premium category attracting the highest level of premium. "practising full-time" means practising for 35 hours or more per week or, in the case of a general practitioner, having gross billings of $100,000 or more per annum. INSURANCE REGULATION ORDER 2001 - REG 2 Premium relativities for obstetrics and neurosurgery 2 Premium relativities for obstetrics and neurosurgery (1) In respect of any category of insurance offered by an insurer, the insurer must provide approved insurance for the categories of medical practitioners referred to in this clause in accordance with the following requirements concerning maximum premium relativities: (a) the annual premium for the maximum premium category of non-exempt medical practitioners with specialist qualifications covered for the practice of obstetrics must not exceed 20 times the annual premium for any premium category applying to non-exempt practising full-time general practitioners who are not covered for the practice of obstetrics, anaesthetics, surgical or elective cosmetic procedures, and (b) the annual premium for the maximum premium category of non-exempt medical practitioners with specialist qualifications covered for the practice of neurosurgery must not exceed 20 times the annual premium charged for any premium category applying to non-exempt practising full- time general practitioners who are not covered for the practice of obstetrics, anaesthetics, surgical or elective cosmetic procedures, and (c) the annual premium for any premium category of non- exempt practising full-time general practitioners who are covered for the practice of obstetrics must not exceed 4 times the annual premium charged for the premium category applying to non-exempt practising full-time general practitioners who are not covered for the practice of obstetrics, anaesthetics, surgical or elective cosmetic procedures. (2) Nothing in this clause prevents an adverse decision being made in respect of an individual medical practitioner which, because of the incident and claims history of that practitioner, results in the practitioner paying an annual premium which is higher than the annual premium for that practitioner’s relevant premium category. (3) Within 28 days of 1 January 2002, and subsequently by the relevant notification date in each year, an insurer is to notify the Director-General, in writing, of the following: (a) the annual premium for the maximum premium category of non-exempt medical practitioners with specialist qualifications covered for the practice of obstetrics applying as at 1 January in 2002 and subsequently as at the relevant notification date, and (b) the annual premium for the maximum premium category of non-exempt medical practitioners with specialist qualifications covered for the practice of neurosurgery applying as at 1 January in 2002 and subsequently as at the relevant notification date, and (c) the annual premium for all premium categories of non- exempt practising full-time general practitioners who are covered for the practice of obstetrics applying as at 1 January in 2002 and subsequently as at the relevant notification date, and (d) the annual premium for all premium categories of non- exempt practising full-time general practitioners who are not covered for the practice of obstetrics, anaesthetics, surgical or elective cosmetic procedures applying as at 1 January in 2002 and subsequently as at the relevant notification date. (4) An insurer is to notify the Director-General, in writing, of any variation to any annual premiums for relevant premium categories required to be notified under sub-clause (2) within 28 days of such variation being made, together with details of the variation. (5) An insurer may elect to provide the information notified under sub-clause (3) and (4) on a commercial in-confidence basis. INSURANCE REGULATION ORDER 2001 - REG 1 Claims handling generally 1 Claims handling generally (1) In this Part: "claimant" means a person who makes a health care claim against a medical practitioner who is covered by approved insurance. (2) On and from 1 April 2002, an insurer is required to comply with the following standards for claims handling and inquiries relating to health care claims, which are not the subject of legal proceedings: (a) the insurer is to prepare all correspondence in plain English, (b) the insurer is to provide a response to the claim within approximately 90 days of its receipt, (c) if the insurer disputes a claim made against an insured medical practitioner, the insurer must provide the claimant with brief written reasons for disputing the claim, (d) if the insurer requests the claimant undertake a medical examination, the insurer must take care to ensure that the medical examination is arranged at a time and place readily accessible to the claimant and to reimburse the claimant’s reasonable travel expenses, and (e) once a claim has been settled, the insurer will pay its contribution to settlement monies within 28 days of settlement, or such other time as may be agreed between the claimant and the insurer, unless the insurer is waiting for receipt of notice of Commonwealth Department of Social Security (however called) payback, Health Insurance Commission payment, or any other demand or notice that has been or will be served on or given to the insurer, or has not yet received payment under relevant re-insurance arrangements. INSURANCE REGULATION ORDER 2001 - REG 2 Early evaluation of claims 2 Early evaluation of claims (1) On and from 1 April 2002, an insurer is required to have in place a process that is designed to enable the early evaluation of health care claims which are not the subject of legal proceedings. (2) The insurer must provide details of the process upon request. Claimants, or their representatives, must be advised in the following terms: (a) that, if they wish to have their claim considered for early evaluation, they must clearly state this in all correspondence, (b) that when the claim is ready to proceed for early evaluation, the claimant must provide a brief statement about: (i) the factual circumstances upon which the claim is based, (ii) details of the negligence they claim has occurred, (iii) a statement about causation, that is, a statement as to how the loss or damage suffered resulted from the medical negligence, (iv) details of damages, that is, the economic loss that the claimant has suffered as a result of the negligence claimed, including loss of wages and earning capacity, hospital and medical expenses, and non-economic loss, that is, the monetary compensation they are seeking as a result of pain and suffering, loss of amenities and loss of expectation of life, and (v) a statement setting out the amounts of damages sought, (c) that claimants must provide medical reports regarding disability and letters supporting any economic loss suffered by the person, (d) that the insurer will not challenge a claim in any court proceedings on the basis that it is outside the limitation period, where the claim is made outside the limitation period only because of the time it took the insurer to determine the person’s claim under the insurer’s early evaluation scheme, (e) that within 60 days the insurer will investigate the matter and advise the claimant in writing in one of the following terms: (i) the insurer is willing to try to resolve the claim and will begin negotiations with the claimant for this purpose, or (ii) the insurer is not willing to try to resolve the claim and the reasons why, (iii) that the insurer is willing to consider the matter further, if the claimant provides additional information which is set out in the insurer’s letter to the claimant. INSURANCE REGULATION ORDER 2001 - REG 1 1 Subject to clause 3 of this Part, within 28 days of the end of each six month period ending 30 June and 31 December respectively, an insurer must provide to the NSW Department of Health: (a) the data specified in Schedule 3 of this order in respect of all policies of approved insurance issued or renewed in that period, and (b) the data specified in Schedule 3 of this order in an updated form in respect of each policy referred to in paragraph (a) to the extent that updated data has become available in that period, and (c) the data specified in Schedule 4 of this Order in respect of each claim, or incident which may give rise to a claim, which is covered by approved insurance reported to the insurer in that period to the extent the data is available to the insurer, and (d) the data specified in Schedule 4 of this order in an updated form in respect of each claim referred to in paragraph (c) to the extent that updated data has become available in that period. INSURANCE REGULATION ORDER 2001 - REG 2 2 By 31 March in each year the insurer is to provide to the NSW Department of Health the information relating to the immediately preceding calendar year specified in Schedule 5 of this order. INSURANCE REGULATION ORDER 2001 - REG 3 3 Within 28 days of 30 June 2002, the insurer is to provide to the NSW Department of Health the data specified in Schedule 4 of this order in respect of each claim or incident, which is covered by approved insurance, reported to the insurer in the immediately preceding three month period to the extent the data is available to the insurer. INSURANCE REGULATION ORDER 2001 - NOTES Note to Part 5Signed at Sydney this 4th day of December 2001. Minister for Health INSURANCE REGULATION ORDER 2001 - SCHEDULE 3 SCHEDULE 3 – Insurance cover information 1 Insurer/Indemnity organisation 2 Record number (non-identifying) 3 Period of indemnity cover (specify start and end date) 4 Area of practice (i) general practice—procedural (non-obstetric)/anaesthetics (ii) general practice—cosmetic (iii) general practice—obstetrics (iv) general practice—other (v) specialist paediatrics (vi) specialist physician—cardiology (vii) specialist physician—neurology (viii) specialist physician—non-procedural gastroenterology (ix) specialist physician—haematology (x) specialist physician—other (xi) specialist anaesthetics (xii) specialist surgery—cardiothoracic (xiii) specialist surgery—colorectal (xiv) specialist surgery—endocrinology (xv) specialist surgery—ENT (xvi) specialist surgery—head and neck (xvii) specialist surgery—orthopaedic (xviii) specialist surgery—urology (xix) specialist surgery—vascular (xx) specialist surgery—maxillo-facial (xxi) specialist surgery—paediatrics (xxii) specialist surgery—neurosurgery (xxiii) specialist surgery—plastic surgery (xxiv) specialist surgery—other (xxv) specialist gynaecology (xxvi) specialist obstetrics (xxvii) specialist ophthalmology—non-procedural (xxviii) specialist ophthalmology—procedural/surgery (xxix) radiation oncology (xxx) pathology (xxxi) radiology (xxxii) radiology—ultrasound diagnostics (xxxiii) specialist dermatology (xxxiv) specialist psychiatry (xxxv) intensive care (xxxvi) emergency medicine (xxxvii) medico-legal (xxxviii) other (specify) 5 Non-standard exclusions on scope of practice (please specify) 6 Gross billings from medical practice: (i) < $100 000 (ii) $100 000—< $250 000 (iii) $250 000—< $500 000 (iv) $500 000 + 7 Average number of hours per week engaged in medical practice (specify) 8 Primary practice context/s (specify one or more contexts where 20% or more of time is spent) (i) Salaried medical officer (public hospital)—rights of private practice (ii) Public hospital visiting practitioner appointment (iii) Private hospital visiting practitioner appointment (iv) Licensed day procedure centre practice (v) Private clinic/rooms (vi) Community health practice (vii) Other (please specify) 9 Policy status: (i) New (ii) Renewed (iii) Lapsed 10 Date of data submission INSURANCE REGULATION ORDER 2001 - SCHEDULE 4 SCHEDULE 4 – Claims information 1 Claim record number (non-identifying) 2 Policy/member record number (non-identifying) 3 Date of notification of claim (including any incident which receives a claims estimate upon notification) 4 Date of incident related to claim 5 Date of civil claim lodgement (commencement of legal proceedings) 6 Gender of claimant 7 Age of claimant at date of incident: (i) baby (0 to < 1 year) (ii) child (1 to < 18 years) (iii) adult (18 + years) 8 Compensation cost estimate (insurer’s best estimate until finalisation) 9 Date of claim finalisation (date of settlement/verdict) 10 Compensation cost (actual total amount when finalised) 11 Type of claim: (i) common law personal injury (ii) nervous shock (iii) compensation to relatives (iv) Fair Trading/Trade Practices (v) Anti-Discrimination Act claim 12 Type of injury (could include more than one category): (i) death (ii) brain/spinal injury (birth) (iii) brain/spinal injury (paediatric) (iv) brain/spinal injury (adult) (v) other personal injury (please specify) 13 Practice context at time of incident: (i) public hospital (non-chargeable patient) (ii) public hospital (chargeable patient) (iii) community health (iv) private hospital/licensed day procedure centre (v) private clinic/rooms 14 Area of practice at time of incident: (i) general practice—procedural (non-obstetric)/anaesthetics (ii) general practice—cosmetic (iii) general practice—obstetrics (iv) general practice—other (v) specialist paediatrics (vi) specialist physician—cardiology (vii) specialist physician—neurology (viii) specialist physician—non-procedural gastroenterology (ix) specialist physician—haematology (x) specialist physician—other (xi) specialist anaesthetics (xii) specialist surgery—cardiothoracic (xiii) specialist surgery—colorectal (xiv) specialist surgery—endocrinology (xv) specialist surgery—ENT (xvi) specialist surgery—head and neck (xvii) specialist surgery—orthopaedic (xviii) specialist surgery—urology (xix) specialist surgery—vascular (xx) specialist surgery—maxillo-facial (xxi) specialist surgery—paediatrics (xxii) specialist surgery—neurosurgery (xxiii) specialist surgery—plastic surgery (xxiv) specialist surgery—other (xxv) specialist gynaecology (xxvi) specialist obstetrics (xxvii) specialist ophthalmology—non-procedural (xxviii) specialist ophthalmology—procedural/surgery (xxix) radiation oncology (xxx) pathology (xxxi) radiology (xxxii) radiology—ultrasound diagnostics (xxxiii) specialist dermatology (xxxiv) specialist psychiatry (xxxv) intensive care (xxxvi) emergency medicine (xxxvii) medico-legal (xxxviii) other (specify) 15 Clinical incident category alleged in claim (could include more than one category of alleged incident): (i) (a) Failure – foetal abnormality – other (non-obstetric) (b) Incorrect – foetal abnormality – other (non-obstetric) (c) Delayed – foetal abnormality – other (non-obstetric) (ii) (a) Non-attendance issues (b) Delayed attendance issues (c) Patient monitoring issues (d) Delegation issues (e) Patient follow up issues (iii) (a) No valid consent (b) Failure to warn (iii) (a) Procedure issues – wrong procedure – wrong body site – failure to perform or complete (b) Post-operative complications – elective/non-elective (specify) – open/endovasive (specify) (c) Failure of procedure issues – sterilisation – other (iv) (a) Complications (b) Medication related (c) Blood/blood product related (d) Failure of treatment related (e) Monitoring/resuscitation related (v) (vi) (a) Epidural related (b) Medication related (c) Equipment related (d) Monitoring/resuscitation related (e) Patient awareness related (f) Other (vii) (a) Diagnosis issues – failure – condition of pregnancy – condition of labour – incorrect – condition of pregnancy – condition of labour – delayed – condition of pregnancy – condition of labour (b) Complications – maternal – delivery – post-partum – neonatal – delivery – post-partum (viii) (ix) (x) (xi) 16 Claim status: (i) Current (ii) Finalised 17 Claim finalisation: (i) Discontinued (ii) Settled—nil payment (iii) Settled—payment (iv) Court award (v) Verdict in favour of defendant 18 Claim cost components (for settlements please estimate): (i) Non-economic loss (ii) Economic loss—care (iii) Economic loss—other (iv) Medical costs (v) Plaintiff legal costs (vi) Defendant external legal costs 19 Other defendant/s (specify category): (i) medical practitioner/s (or medical practitioner’s practice company) (ii) public health organisation (iii) private hospital (iv) day procedure centre (v) registered health practitioner (or practice company) (vi) unregistered health practitioner (vii) product manufacturer/distributor (viii) corporation providing medical/medical practice support services (excluding individual practice companies) (ix) other (specify) 20 Contribution amount (when finalised) 21 Date of data submission INSURANCE REGULATION ORDER 2001 - SCHEDULE 5 SCHEDULE 5 – Annual report by insurers 1 Risk management activities (a) details of initiatives undertaken to identify problems (specifying which problems have been identified) in relation to particular categories of medical services (identify which particular categories of medical services); (b) details of initiatives undertaken to identify problems (specifying which problems have been identified) in relation to individual medical practitioners (specifying the number of individual medical practitioners concerned in relation to each identified problem); (c) details of initiatives undertaken to provide strategies to effectively deal with the problems identified pursuant to paragraphs (a) and (b) above; (d) in relation to the activities referred to in paragraphs (a), (b) and (c) above: (i) the number of employee and contractor hours involved in risk management activities in the immediately preceding calendar year, (ii) the projected number of employees and contractors involved in risk management activities for the calendar year in which the report is being made, (iii) the qualifications of each person engaged in risk management activities in the immediately preceding calendar year, (iv) the percentage of gross annual premium income spent on risk management activities in the immediately preceding calendar year, and (vi) the percentage of gross annual premium income the insurer has budgeted to spend on risk management activities in the calendar year in which the report is being made. 2 Adverse incidents (i) Report of any identified adverse incident trends for each category of specialty covered (ii) Report of measures undertaken by insurer to address identified adverse incident trends 3 Claims handling (i) Number of claims handled through early evaluation process (ii) Number of claims for compensation received without legal proceedings being lodged (iii) Number of claims for compensation resolved without legal proceedings being lodged 4 Terms and conditions of indemnity cover Details of insurer’s standard insurance policy terms and conditions and/or conditions of discretionary indemnity cover. INSURANCE REGULATION ORDER 2001 - NOTES Note: The Order was repealed by Gazette No 116 of 25.7.2003, p 7500, with effect from 25.7.2003. INSURANCE REGULATION ORDER 2001 - NOTES Historical notes The following abbreviations are used in the Historical notes: ______________________________________________________________ |______________________________________________________________| |______________________________________________________________| |______________________________________________________________| |______________________________________________________________| |______________________________________________________________| |______________________________________________________________| |______________________________________________________________| Table of amending instrumentsInsurance Regulation Order 2001 published in Gazette No 190 of 14.12.2001, p 10052 and amended as follows: Insurance Regulation Order—Amendment (GG No 154 of 27.9.2002, p 8457) Table of amendments ________________________________ |________________________________| |________________________________| |________________________________| |________________________________| |________________________________|