Q. How do you get a medical leave of absence?

A. If you work for a company with fifty or more employees you may qualify for the Family Medical Leave Act, which typically allows up to twelve weeks for unpaid leave, or more if you are in the military. Also, your state may have its own laws that complement FMLA or add to this leave. Check with the Department of Labor in your state.

Q. What are the basic maternity leave laws?

A. This depends on the state, but the Family Medical Leave Act typically allows up to twelve weeks for unpaid leave. Also, your state may have its own laws that complement FMLA or add to this leave. Check with the Department of Labor in your state.

Q. What is the difference between claims-made & occurrence malpractice?

A. Claims-made covers you for claims submitted while the policy is in force, and also for a tort that occurred from the retro date through the date of the current policy. Occurrence policy covers claims that occurred during the policy period, and the policy does not have to be in force.

Q. Do IPA’s need medical malpractice insurance?

A. No, but they do need industry specific errors and omissions, and directors and omissions insurance that include vicarious malpractice, which cover the IPA’s risk for malpractice.

Q. What’s the difference between medical malpractice and errors and omissions?

A. They both cover errors; but, Medical Malpractice covers physicians for direct medical care and Errors and Omissions cover a business if it makes an error.

Q. What do statutory limits mean on a worker’s comp policy?

A. In many states you cannot sue an employer for more than $1 million by law, excepting gross negligence; therefore, it is a law, so the insurance policy models the statute’s limits.

Q. What is an excess worker’s comp policy?

A. It is for employers who self insure their worker’s comp. They buy excess or stop loss insurance. This insurance limits the employer’s exposure to unexpected total claims, or the specific claims of one person.

Q. What is excess of limit losses in workers compensation?

A. This can refer to an excess policy, which you can buy over a fully insured policy. Normally, workers compensation is limited to the statute, but if gross negligence can be proven then a claimant can sue for more than the limits of statute. If this happens, and the employer has an Umbrella policy, it may respond to the claim that exceeds the limit of the workers compensation policy.

Q. What is worker’s compensation aggregate retention?

A. This is the total amount of claims that you, the employer, pays until the insurer starts paying.

Q. How do you account for workers compensation aggregate stop loss deductible?

A. When you purchase aggregate stop loss for your self-insured workers compensation, the insurer will define upfront what the aggregate is. Your TPA, or third party administrator, should give you periodic aggregate reports showing the total amount of claims paid as they accumulate toward meeting the aggregate stop loss deductible.

Q. What are reinsurance triggers in healthcare?

A. It depends. Health insurers can have a defined dollar amount where they are laying risk off to a reinsurer. For example, a health insurer may buy a $100K of specific reinsurance coverage; thus, if one patient hits a $100K, then every dollar above that amount will be reimbursed by the insurer.
Q. What are the two types of stop loss in hospitals?

A. 1.Specific stop loss covers the hospital for claims that exceed a defined dollar amount for a patient. For example, the hospital for its self insured health plan, or its capitated members, can buy a $100K of specific stop loss deductible, which means the insurer will pay all claims that exceed $100K.

2. The other is aggregate stop loss which covers the hospital for all the claims it pays out in its self insured plan. For example, the insurer will cover you if your total claims paid in the year exceed $5 million. The insurer will reimburse the amounts that exceed that amount.

Q. Does a third party FMLA administrator have the right to contact your healthcare provider?

A. Yes, they have the right to ask for a second opinion, and/or have your doctor complete a form. But contacting them directly, I doubt, would be effective because the MD cannot talk with them due to HIPAA.

Q. What does it mean if your HMO sent a letter saying you have reached the catastrophic portion of your policy?

A. This can possibly mean that you have reached the maximum out of pocket limit.

Q. Can my employer stop my health care when on workers compensation?

A. Yes, they need to put you on COBRA. Health insurance requires that you are to actively working full time. When you are out on a worker’s compensation claim, you cannot meet this requirement.

Q. How can a company process employees’ medical claims?

A. The employer, if it is big enough, can take their claims in house and act as a TPA. Most companies do not do this anymore due to HIPAA concerns; most outsource this to an independent TPA.

NOTE: THE ABOVE IS A GENERAL DISCUSSION ABOUT HOW COVERAGES MAY WORK. YOUR INSURANCE POLICY AND ALL ADDENDA ARE THE ONLY AUTHORITY OF HOW YOUR COVERAGE WORKS. DO NOT RELY ON THIS ARTICLE AS AN EXPLANATION OF YOUR COVERAGE. HAVE YOUR ATTORNEY REVIEW YOUR ENTIRE POLICY WITH YOU TO DETERMINE WHAT IS AND IS NOT COVERED.

By William D. Dyer

Q: What the meaning of equal employment opportunity?
A: This typically applies to a business with fifteen or more employees that prohibits discrimination in any aspect of employment and harassment in the workplace based on race, color, age (40 and over), sex, pregnancy, gender, religion, disability, national origin, ethnic background, military service, and/ or citizenship.

Q. What is the ballpark estimate for directors and officer liability insurance?

A. It can be as low as $1,200 for a small business, to millions for a public company

Q. What is the typical annual premium for D&O in small business?

A. Typically it is $1,200 to $5,000.

Q. What is the cost for errors and omissions coverage?

A. This depends on the limits, industry, geographic location, and past claims experience. Some of the most expensive professions would be MD’s, Real Estate Brokerages, and Appraisal Firms, Insurance Brokerages, Engineering Firms and Law Firms.

Q. How do you apply for errors and omissions insurance?

A. You contact an insurance broker with expertise in E&O (it is an insurance specialty). The broker will have you complete an application; if you have coverage currently they will obtain your loss runs for the past five or ten years. The broker will shop your coverage to multiple insurers.

Q. How much is a $100,000 of general liability?

A. Assuming you are not in something risky, an estimate would be $100 to $500 a year. Most companies buy this coverage with limits in the millions.

Q. What is product professional liability?
A. As it implies in its name, it protects you from suits relating to the products that you produce, or a private label.

Q. Can an employer stop group health benefits during workers compensation claims?

A. Yes; and the employer should. You have to check with your health insurer to see what the contract dictates, but most have a limitation that coverage is for full time employees working twenty-five or thirty hours a week. If an employee is on Workers Compensation, he/she is not working, so therefore, he/she is no longer eligible for group health insurance. You should offer him/her COBRA. If you do not do this, the health insurer can deny the claims of the employee. We know of an employer, which is not our client, who kept an employee on his/her group health insurance while the employee was on Workers Compensation. The employee had a massive heart attack while he/she was disabled. The employee mentioned it to the doctor, and it was entered into his medical record that he was out on a Workers Compensation claim. The employee was given open heart surgery that yielded a big bill, which the insurer denied since the employee was not eligible for health insurance at the time of the claim. The employer was sued for the bill and lost in court.

Q. Can you run a CA Family Rights Act with the Federal Family and Medical Leave Act?
A. Yes, CFRA and FMLA can run concurrently.

Q. Is excess workers compensation a liability policy?

A. Not excess, which usually refers to reinsurance – a self insured Workers Comp. However, if the question is, can you buy excess coverage or umbrella insurance to supplement the liability portion of Workers Compensation, the answer is yes. This is one of the reasons why one buys an umbrella for one’s company. If the Workers Comp limits are breached or used up, then the umbrella may respond. Please note that most states limit the liability for the employer to the limits of the Workers Comp policy unless there is gross negligence.

Q. What is worker’s comp aggregate retention?

A. If you self insure your Workers Comp and say if the past five years show your average claims with an inflation of $3,000,000 then a reinsurer may sell you an aggregate reinsurance policy that will pay all claims that exceed the expected claims of $3,000,000. The $3,000,000 is the aggregate retention or deductible.

Q. Where can you buy medical malpractice coverage while on the US rotation?

A. If you are a resident of the US, you can buy it from a typical malpractice insurer. The problem is the policy will be for one year, so if you are here for less than one year, you will want to pay the premium and request a refund for any unused premium and buy tail insurance. Tail insurance is to cover you for any claims that occurred during the time you were covered. If you are returning to your home country and never plan to live in the US, you will want to consult an attorney to see what your exposure is versus buying tail insurance. When in doubt, buy tail insurance.

NOTE: THE ABOVE IS A GENERAL DISCUSSION ABOUT HOW COVERAGES MAY WORK. YOUR INSURANCE POLICY AND ALL ADDENDA ARE THE ONLY AUTHORITY OF HOW YOUR COVERAGE WORKS. DO NOT RELY ON THIS ARTICLE AS AN EXPLANATION OF YOUR COVERAGE. HAVE YOUR ATTORNEY REVIEW YOUR ENTIRE POLICY WITH YOU TO DETERMINE WHAT IS AND IS NOT COVERED.

By William D. Dyer

Q: What is EPLI Insurance?
A: EPLI Insurance or Employment Practices Liability Insurance covers the employer for exposures relating to employment (i.e. discrimination, wrongful termination et al).

Q: What’s the difference between term life insurance and whole life insurance?
A: Term insurance is for people who do not want life insurance to be paid when they die of old age. It is normally purchased to cover a ten or twenty year period, like when someone with young children wants coverage in case they die prematurely. The premiums are cheap, but they skyrocket at the end of the term, so most people cancel the coverage. It seldom results in a claim, since most people who buy term buy it when they are young and healthy. If there is a term life death claim, it is usually the result of an accident or a premature death due to an unexpected disease.
Whole Life insurance is as the name implies, it covers your entire life. This insurance is for someone who wants coverage for their entire lifetime. Since this has a greater coverage period, it is more expensive. But on a net basis, whole life is cheaper than term life. When you pay your premiums, a small portion goes to the cost of the life insurance and most goes toward an investment. As you pay your premiums after twenty or thirty years, you likely will have double what you paid in premiums in the investment portion of the policy, called cash value. You can use the cash by borrowing it, or you can leave the cash alone, and it will likely (depending on the design) pay for your premiums for the rest of your life.

Q: What is the average cost of malpractice insurance?
A: We get this question all the time, and it depends on which state, specialty, the year of the retro date and the doctor’s claims. If you want a ballpark, in CA, a non invasive specialty, fully mature, with no claims is $10K a year, and an invasive specialty is $45K. If it is NY, multiply those numbers by three or four.

Q: How much is the most basic professional liability insurance for a small business?
A: It’s tough to say because it depends on what they do for a living, but a ballpark small business is $5K to $10K a year.

Q: What is Personal Injury Medical Malpractice?
A: This is a new insurance that allows the patient to buy life, and a product similar to AD&D for claims arising from complications related to a recent surgery. For example, if you die from complications of a surgery, then your family will get a death benefit. If you lose your limb(s) or other functions, then you get a benefit. This new insurance may lower the chances of claims against the surgeon. First, if a family or patient suffers a loss and they get paid under this policy they may be less likely to sue the doctor since they received compensation. Also, this may help negate a patient or family’s lawsuit claim alleging that the doctor did not provide adequate information regarding the surgical risk, and therefore never obtained informed consent. How would a patient claim that he/she did not know the risks if he/she buys insurance to protect himself/herself from the surgical risk?

Q: FMLA versus workers comp?
A: FMLA is the Family Medical Leave Act. This provides job protected leave for non job related illness or leave to care for an immediate family member. Workers Comp provides benefits for job related injury disability or death.

Q: Are most ASO also stop loss?
A: ASO is administrative service only. These are the services that the employer needs to self-insure its health insurance; the business that performs this is called TPA, or third party administrator. ASO includes claims processing, utilization review, case management, PBM-pharmacy benefit manager, and PPO.
Stop Loss is the insurance that the employer buys to cover himself/herself for catastrophic claims that exceed a defined dollar amount (i.e. $50K or $100K). He/she would also purchase Aggregate Stop Loss Insurance. This covers the employer if his/her total annual claims exceed a defined amount of money. So do all ASO plans have stop loss? Not always. There are large employers who have thousands of covered employees that may feel they do not want to purchase stop loss, since their risk is very predictable. When it is not predictable, they have the necessary funds to cover bad years.

Q: Why do you have to issue a broker of record to a broker?
A: This is done when you want to hire a new broker to handle your insurance. Perhaps you currently have the best deal on your insurance, but you find another broker who provides more services than your current broker, and you want to change. You simply sign a letter addressed to all your insurers with your policy number which states, “I am appointing broker X as my new broker and please pay him/her the normal commissions that are being paid in relation to my insurance.” You should think about why you are changing brokers. Some clients sign this without knowing what it means or they think it is no big deal. It means the person who is handling your insurance now is going to be fired. It is similar to firing an employee. You would not do this for any particular reason. Also, do not do this midway into the policy if it is for group benefits. Inform your current broker, and make the change thirty days prior to renewal. Since the current broker did the work of shopping for all your coverage for free, and he/she is paid a monthly commission throughout the year, if you fire him/her midway into his/her policy then that money goes to the new broker for doing nothing. For all other insurance coverage you can make the change anytime after the renewal, since the broker gets paid the entire commission at the time of binding your renewal.

Q: What are reinsurance triggers in healthcare?
A: Not sure, but reinsurance can trigger on a specific basis, meaning a defined deductible amount or it can be a quota share where the reinsurer takes a percentage of risk over a certain dollar amount.

Q: What does D and O insurance mean?
A: Directors and Officers Insurance protects the current and former officers, directors, managers, and employees for claims arising from the operations of the company (not professional liability).
Example: an anti-trust claim or misuse of corporate assets or business interference.

Q: What does a statutory limit mean on a worker’s comp policy?
A: Workers Compensation covers all employees for work related injuries at 100% of the medical bills. It has a disability benefit and life insurance. In return for these free benefits, the worker cannot sue the employer for more than what the statute says. In California, this is $1 million. The only way to get more than this limit is if the worker can prove gross negligence.
Example: an employer knew he had a faulty machine and let an employee use it and he/she is severely injured or killed. This is why all employers, especially those who can have a big worker’s comp claim should buy umbrella liability insurance, since this is the coverage that may respond if you have a claim that exceeds the workers compensation statutory limit. General Liability will not respond.

HCP National Insurance is a provider of Errors and Omissions, Professional Liability, and General Liability Insurance for small businesses. We are experts in small business insurance, health care insurance, D and O and E and O insurance, medical malpractice insurance, and all other insurance coverage. Our home office is located in Aliso Viejo, CA.

NOTE THE ABOVE IS A GENERAL DISCUSSION ABOUT HOW COVERAGES MAY WORK. YOUR INSURANCE POLICY AND ALL ADDENDA ARE THE ONLY AUTHORITY OF HOW YOUR COVERAGE WORKS. DO NOT RELY ON THIS ARTICLE AS AN EXPLANATION OF YOUR COVERAGE. HAVE YOUR ATTORNEY REVIEW YOUR ENTIRE POLICY WITH YOU TO DETERMINE WHAT IS AND ISN’T COVERED.

[Credit: NORCAL Mutual Insurance Company, Spring 2010 Issue]

Californian physician have some of the lowest cost medical malpractice insurance in the country, as a result of MICRA. Though many MD’s feel they pay a fortune, this is primarily due to the fact that they earn less in CA than MD’s who practice in other states.

The Medical Injury Compensation Reform Act (MICRA), the 1975 California law, that helps control healthcare costs, is safe for another year, at least on the legislative front. The deadline to introduce legislation in California this year has passed, so barring a last minute “deal,” MICRA will not be under attack in 2010. However, there are currently at least three cases challenging the MICRA cap on noneconomic damages in the California courts. NORCAL Mutual is encouraged by the recent Van Buren v. Evans decision in the Fresno Appellate Court that upheld the cap.

The relatively favorable climate in California is in stark contrast to the dismal situation in Georgia and Illinois, where the courts recently tossed out caps on noneconomic damages. The Georgia Supreme Court held that the cap violated the Georgia State Constitution’s equal protection clause, while the Illinois Supreme Court ruled that the cap ran afoul of the state constitution’s guarantee of right to trial by a jury.

These setbacks to tort reform in other states remind us that we must remain vigilant in defending MICRA in California. As NORCAL Mutual Board Chair, David Holley, MD, recently told executives of our endorsing medical societies, “Organized medicine is doing a good job of defending MICRA in California, but we can’t become complacent. The threats are ongoing and real. NORCAL Mutual is actively involved with several broad-based coalitions to augment the efforts of organized medicine in defending MICRA in forums spanning the legislature, courts and public opinion.”

HCP National Insurance is a national medical malpractice and medical professional liability broker appointed by Norcal. HCP National’s Medical Malpractice Insurance brokerage is located in Orange County, CA.

We’ve seen questions go through our que quite a bit, so we decided to do a monthly Q&A to get these questions answered. Feel free to ask follow up questions or even new questions, in the comments.

Q: When filing a worker’s comp claim in California, when will the employer stop health coverage for an employee?
A:If the employee will not be actively at work or working full time, 30 hours a week in general, (please check your health insurance plan document), then the employer should put the employee on COBRA . Be aware that some workers comp insurers will advise you to keep the employee on health insurance for an indeterminate length of time. They advise this as a way to not anger the employee. This is very bad advice. If your health insurance states, which many plan descriptions do, that to be eligible for health insurance you have to be working a certain number of hours a week on a full time basis, it means it. Just because you choose to keep them on the plan and pay their premium does not mean they are covered.

Example: We heard of an employer who kept an employee on the plan while an employee was out for 6 months due to a work related back injury. The employee had a heart attack, while on his WC leave, and needed open heart surgery. In the physician’s notes, the patient told him he had been on WC leave. The health insurer denied the claim, since the employee was not eligible for health insurance. The employee sued the employer for the $150,000 hospital bill.

Q: What is HMO reinsurance?
A: It is insurance that an HMO would purchase from an insurance company who agrees to share in a defined part of risk for a defined premium. One of the most common types of HMO reinsurance is stop loss reinsurance. An HMO might feel that it can pay all claims for the first $200,000 of medical expenses for any one member, but it does not want to absorb expenses beyond this level. The HMO agrees to pay an outside reinsurer who will reinsure the HMO, and reimburse it for claims above $200,000. The HMO will pay that reinsurer a per-member, per-month premium (pmpm). The pm pm pricing is the basis for the premium. The other typical reinsurance option is quota share reinsurance.

Q: What coverage do I need for my medical malpractice?
A: In California the norm for medical malpractice insurance is $1 million per occurrence and $3 million per policy aggregate. Other states have higher or lower limits depending on the rules and regulations within the state. If a doctor has privileges, his/her hospital will dictate the limits, and the hospital will know of any laws relating to these limits. If you do not have hospital privileges, ask your medical malpractice broker what is typical. There are 2 kinds of medical malpractice claims made: medical malpractice insurance and occurrence medical malpractice. Most doctors purchase claims made since it is more affordable.

Q: Employee benefits rescinding broker of record, who gets commission?
A: Commissions are paid monthly by the insurance company as you pay your premiums. If you fire agent A on 2/28 and hire agent B, and 2 days later, on 3/2, you rescind the broker of record on Agent B and rehire Agent A, odds are Agent A will not lose any money and Agent B gets paid nothing. The norm is that the insurer will give the current broker, in our example, Agent A, 10 days to receive rescindment of the broker of record. After 10 days the commission for March will be paid to Agent B. After 10 days if you fire Agent B and rehire Agent A, then Agent B will have 10 days to rescind the broker of record.

Q: How can public entities save money?
A: Competition is the key to saving money on insurance. You want a few insurance brokers working on your insurance. It is a lot of work, but the best way is to get multiple bids from 2 or 3 brokers including the incumbent. However, you need to be available to give the non-incumbent brokers the information they need to quote. We find many public entity purchasing departments favor the incumbent broker since he/she has all the loss run information and applications necessary to shop the insurance. The outside broker has little chance of competing unless you have a very diligent purchasing department at the public entity, which gets you the necessary information and answers questions in a timely fashion. We have seen very good purchasing departments, and many who are unresponsive, so the insurance stays with the same broker forever because you cannot get the necessary information to give a competitive quote and the public entity is then left paying more. Other ideas include hiring an insurance consultant to review your RFP to make sure that every item necessary to shop the insurance is included. This includes typical Q & A’s, and have the brokers provide their #1 through #3 favorite insurers for your risk, along with the premium that they have with those insurers. If more than one broker picks the same #1 insurance company, allow the broker with the most premium to have the #1 choice. The more premiums that a broker has with the insurance company, the better their relationship will be.

Q: What is excess workers comp?
A: This is for large to medium sized employers who want to self insure their workers compensation. They can purchase excess or stop loss reinsurance. This protects the employer from large claims.
Example: The employer has very predictable experience, but he/she wants to buy excess workers compensation insurance with a $100K deductible. So for claims below $100K, the employer pays. For any claims that exceed $100,000, he/she submits for reimbursement to the excess workers comp carrier with whom he/she purchased the excess reinsurance policy.

NOTE THE ABOVE IS A GENERAL DISCUSSION ABOUT HOW COVERAGES MAY WORK. YOUR INSURANCE POLICY AND ALL ADDENDA ARE THE ONLY AUTHORITY OF HOW YOUR COVERAGE WORKS. DO NOT RELY ON THIS ARTICLE AS AN EXPLANATION OF YOUR COVERAGE. HAVE YOUR ATTORNEY REVIEW YOUR ENTIRE POLICY WITH YOU TO DETERMINE WHAT IS AND ISN’T COVERED.