Physicians ask if their Medical Malpractice Policy will Cover them for Independent Medical Evaluatio

August 21, 2020

Independent Medical Evaluation Liability Insurance

Many physicians ask if their Medical Malpractice Insurance Policy will cover them for independent medical evaluations. As in most situations involving coverage issues the answer is it depends. The important steps to take are to run it by your broker agent or underwriter.

The ‘Opinion or Consultation Claims’

Many professionals are asked to review files and offer their evaluation, opinion or consultation on medical treatment and protocol. These kinds of claims are not contemplated by medical malpractice policies, so these kinds of claims are often denied. Medical malpractice policies are written to respond to claims of bodily injury caused by acts of medical care diagnosis or omissions. Insurance policies are triggered by the specific claim outlined in the contract. Loss of property claims, claims caused by fire theft, and injury resulting from negligence in the rented office space are all specifically outlined and protected by General/Commercial Liability Insurance. Similarly, medical malpractice claims are narrowly defined, and the “trigger” to the policy requires somewhat conventional medical service.

Independent medical evaluations are outside of the physician patient care contemplated by many of these insurance policies. Reviewing files, medical history, comparing cases and assessing care can result in financial loss for plaintiffs who might be depending on medical or workers compensation payments and benefits. These claims presented by insured or sick workers against the physician “expert” are insurable. The allegation of financial loss caused by a professional can bring dentists, chiropractors, medical doctors, and others into costly claims.

Sample Professional Liability Claim for Expert Opinion

In a case recently documented, both a physician and dentist were drawn into a claim over a denial of benefits. The plaintiff in the case wanted an exam from the doctor, while the insurance company wanted the exam from the dentist. Both the plaintiff and the insurance company were unhappy with the professional evaluation and all ended up incurring defense expenses. The plaintiff sued the benefits insurer for failing to pay for TMD treatment, which the insurer refused to provide unless the plaintiff underwent an IME with the dentist. The court immediately sided with the insurer, finding that it was entitled to an IME by the dentist. The plaintiff refused on the basis that there was no right to be examined by the dentist, as the policy only permitted examination by a qualified medical practitioner.

These claims and situations create conflict. Naturally, the plaintiff and insurance carrier are often on opposite sides. The plaintiff’s best interests are not always the insurance company’s, therefore those contracted to provide the independent medical evaluation are in a tough spot.

The Affordable and Available Solution

Medical professional liability policies will many times simply deny these claims. When an insurance carrier denies it, that’s usually it, but is followed by anxiety, time, and expense. These policies, usually underwritten by Lloyd’s of London Specialty Divisions, are written to respond to the representations made on the application and in the accompanying electronic communication that support the submitted application. The underwriters will spend some time understanding the unique type of expert opinion or independent evaluation and rate, and then develop the policy accordingly. These policies cover a broad category of medical directors, administration, supervision, independent medical evaluation, workers compensation evaluation, and medical expert witness work, all of which share the common theme of professionals bringing their experience, credentials, and opinions to cases and situations that can cost either side - rather than conventional medical care direct to a patient.

The claims triggers are the consultation itself, and these Medical Expert Professional Liability Insurance policies understand that. Just as you would protect your medical practice with an insurance policy that understands the risk, you can also work with carriers that have developed this very product.

The Doctors Insurance Agency has worked with such carriers that understand how to price and underwrite these policies, and are ready to help you.