Medical Malpractice Instructions
Definition of a health care provider and medical malpractice insurance per Section 383.100:
- Subsection (2) "Health care provider" includes physicians, dentists, clinical psychologists, pharmacists, optometrists, podiatrists, registered nurses, physicians' assistants, chiropractors, physical therapists, nurse anesthetists, anesthetists, emergency medical technicians, hospitals, nursing homes and extended care facilities; but shall not include any nursing service or nursing facility conducted by and for those who rely upon treatment by spiritual means alone in accordance with the creed or tenets of any well-recognized church or religious denomination
- Subsection (3) "Medical malpractice insurance" means insurance coverage against the legal liability of the insured and against loss, damage, or expense incident to a claim arising out of the death or injury of any person as a result of the negligence or malpractice in rendering professional service by any health care provider.
Definition of who is to file medical malpractice claim data per Section 383.105:
- Subsection (1) Every insurer providing medical malpractice insurance to a Missouri health care provider and every health care provider who maintains professional liability coverage through a plan of self-insurance shall submit to the director of the department of insurance a report of all claims, both open claims filed during the reporting period and closed claims filed during the reporting period, for medical malpractice made against any of its Missouri insureds during the preceding three-month period.
- Subsection (3) As used in this section, "insurer" includes every insurance company authorized to transact insurance business in this state, every unauthorized insurance company transacting business pursuant to chapter 384, RSMo, every risk retention group, every insurance company issuing insurance to or through a purchasing group, and any other person providing insurance coverage in this state. With respect to any insurer transacting business pursuant to chapter 384, RSMo, filing the report required by this section shall be the obligation of the surplus lines broker or licensee originating or accepting the insurance.
Definition of what is a claim, companion claim and date of this payment or closure per Section 383.105:
- A claim/demand for payment of damages is received in writing from claimant, a lien letter was received or a lawsuit has been filed.
- A companion claim, each named defendant that is covered whether or not they are the named insured on the policy or covered employees or agents of a corporation, association or the trust, then any claims made against such employees/agents should be reported as such to our office. For example, if a covered physician and nurse were named as defendants in a medical malpractice claim, (in addition to the hospital) three separate reports would be submitted to our office. Each such defendant is considered a named insured for reporting purposes and should be identified in Item 3a. All indemnity and expenses should be tracked and reported separately for each defendant. Claim identification numbers should be unique for each claim file.
- Date of this payment or closure is defined when the insurer closed the claim.
A Medical Malpractice Claim Report must be submitted when a claim/demand for payment of damages is received in writing from claimant, a lien letter was received or a lawsuit has been filed. An incident is not to be reported until it becomes a claim. All open and closed reports are to be submitted to the Department of Insurance on a quarterly basis and are due in the office 30 days after the close of each quarter. Closed reports are to be filed whether or not payment was made.
When filing an Open claim where no suit has been filed: Complete fields 1a through 12, 26a, 26b, 26c and 26d.
When filing an Open Claim where a suit has been filed: Complete fields 1a through 12, 16a, 16b, 16c, 16d, 16e, 26a, 26b, 26c and 26d.
When filing a Closed Claim all fields must be completed.
Report all dollar amounts in whole dollars, do not include cents. All dates are reported in the format of MM/DD/YYYY.
1a. NAIC Group & Company Code and Name of Insurer: This is an assigned 9 digit code by the NAIC to insurance companies. Self-insured entities need to contact the Department of Insurance for an assigned number
1b. Claim File Identification: Assign a distinguishing claim file identification number to each claim report. This number must be sufficient identification to enable tracing of a particular claim. The Claim File Identification number may only contain letters and numbers (do not use spaces or punctuation).
2a. Date of Injury: Date of alleged injury.
2b. Date Reported: Date when claim was made.
2c. Date Reopened: Date claim was reopened.
2d. Original Claim ID Number if claim is reopened: If claim is reopened, original claim identification number used when claim was originally filed with the Department.
3a. License Number of Health Care Professional: Enter Missouri license number of insured, if the insured is an individual and licensed to practice in Missouri. If the individual is not licensed in Missouri, enter the license number of the most applicable state associated with the injury. If the insured is not an individual, enter the federal identification number (FEIN). The license number of the health care professional can be found at: https://renew.pr.mo.gov/licensee-search.asp.
3b-3e. Name of Insured: Enter name of insured against whom the claim is being made.
3f. Age of Insured: Enter age of insured identified in 3b as of the date of injury. This field should not be completed if insured is an institution, group or partnership.
3g. City: Enter city of residence of the insured named in 3b.
3h. State: Select the residence of the insured, named in 3b, with two letter state abbreviation.
3i. Zip: Enter the residential zip code of insured named in 3b.
4a. Profession Code of Insured: Select appropriate code for insured named in 3b.
(1) Physicians and Surgeons
(4) Nursing Homes
Note that codes 1, 3, 5, 7, 8 and 9 should only be used for individuals. If the insured is an institution or corporate entity other than a hospital, nursing home or pharmacy, code as “0”. The code of “0” should also be used for all individuals that are not licensed in one of the medical professions listed in 1, 3, 5, 6, 8 and 9. For example, a dental hygienist should be coded as “0”, not “5”. A physician assistant should be coded as “0” and not “1”. If in doubt, please contact this office.
4b. Specialty Code: Select appropriate five-digit specialty code. The specialty code must correspond with the profession code entered in item 4a. Please note that many specialty codes are for use only with individuals and some are for use only with institutions. For example, the specialty code “80421 – Family Physician/General Practice” is reserved for use with individual physicians. A list of MDI codes to use in this field is http://insurance.mo.gov/industry/filings/stats/medmalspec.php
4c. Type of Practice: Select one of the following codes if the insured named in 3b is a physician or other medical professional. Not applicable if hospital or healthcare facility is the insured.
(1) Institutional (including academic)
(2) Professional Corporation or Partnership (Group)
(4) Employed Physician
(5) Employed Nurse<
(6) All Other Employees
(7) Intern or Resident
5a. Place Where Injury Occurred: Select the appropriate code for the place where the principal injury occurred:
(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)
If the claim resulted from a diagnostic error, code place where error occurred, regardless of where it was discovered or treated.
5b. City: Enter city for place of injury coded in 5a.
5c. State: Select two-letter state abbreviation for place of injury coded in 5a.
5d. Zip: Enter zip for place of injury coded in 5a.
6a. Name of Institution: Enter name of institution, if injury occurred in an institution (5a should be coded 1, 2, 3, 4, or 7).
6b. Location of Institutional Injury: Select appropriate code for location within institution where injury occurred:
(1) Patient’s Room
(2) Labor and Delivery Room
(3) Operating Suite
(5) Critical Care Unit
(6) Special Procedure Room
(9) Physical Therapy Department
Applicable only when 5a is coded 1 or 4.
7a-k. Injured Person’s Identification: Enter last name, first name of injured person, age on the date of injury, sex of injured person as ‘M’ (male) or ‘F’ (female), date of birth, street address, city, state, zip and telephone number of injured person.
8a-h. Person Instituting Claim if Injured Party is Deceased or a Minor: Enter last name, first name, street, city, state, zip and telephone number of person instituting claim.
9a-d. Plaintiff Attorney’s Identification: Enter name, city, state and zip of attorney.
10a-e. Nature and substance of claim: Give a complete description of all actions and circumstances causing the claim. Include allegations made by claimant and provide as much detail as is available. Your narrative should include a minimum of four items: the illness or condition for which treatment was sought, the type of treatment or medical intervention rendered, the alleged error or omission leading to the injury AND the nature of the injury and any subsequent complications or additional injury.
11a. Allegation and Code: Identify allegation(s) and related three-digit code(s), same codes used by National Practitioner Data Bank. Be sure to use most specific allegation codes when available. For example, do not enter “201 – Delay in Treatment” if “203 – Delay in Treatment of Identified Fetal Distress” is more appropriate. http://insurance.mo.gov/industry/filings/stats/allegation.php.
12. Severity of Injury: Select severity of injury from scale provided below. Code the most serious outcome if several injuries are involved.
Severity of Injury variables are provided below.
Temporary (1) Emotional Only: Fright, no physical damage
Temporary (2) Insignificant: Lacerations, contusions, minor scars, rash. No delay.
Temporary (3) Minor: Infections, misset fracture, fall in hospital. Recovery delayed.
Temporary (4) Major: Burns, surgical material left, drug side effect, brain damage. Recovery delayed.
Permanent (5) Minor: Loss of fingers, loss or damage to organs. Includes non-disabling injuries
Permanent (6) Significant: Deafness, loss of limb, loss of eye, loss of one kidney or lung.
Permanent (7) Major: Paraplegia, blindness, loss of two limbs, brain damage.
Permanent (8) Grave: Quadriplegia, severe brain damage, lifelong care or fatal prognosis.
Permanent (9) Death
13. Date of this Payment or Closure: Enter date. When reporting a reopened case, enter new closure date.
14. Claim Disposition Code: For all claims, select final method of claim disposition:
(1) Settled by parties prior to trial.
(2) Settled by parties after trial.
(3) Disposed of by court.
15. Settlement Code: Select the appropriate 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
(5) After judgment or decision, but before appeal
(6) During appeal
(7) After appeal
(9) During review panel or nonbinding arbitration
16a. Court Code: For all claims, select the appropriate court code:
(0) Not disposed by court, claim closed by settlement or was abandoned or other means
(1) Direct verdict for plaintiff
(2) Direct 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) Judgment for plaintiff after appeal
(8) Judgment for defendant after appeal
(9) Case dismissed or other court action
16b-d. Name of Court, Docket Number and Date Suit was Filed: Enter full name of court, docket number and date suit was filed. The Docket number may only contain letters and numbers (do not use spaces or punctuation). This information can be found at: https://www.courts.mo.gov/casenet/base/welcome.do
16e. County FIPS Code: Identify County FIPS Code of court location. http://insurance.mo.gov/industry/filings/stats/district.php
17a. Indemnity Paid by you on Behalf of this Defendant: Enter indemnity paid by you on behalf of this defendant. If more than one policy is involved, total the amounts paid by you under all policies.
17b. Economic Damages: Enter from item 17a, the amount of damages arising from pecuniary harm including, without limitation, medical damages and those damages arising from lost wages and lost earning capacity.
17c. Non-Economic Damages: Enter from item 17a, the amount of damages arising from non-pecuniary harm including, without limitation, pain, suffering, mental anguish, inconvenience, physical impairment, disfigurement, loss of capacity to enjoy life and loss of consortium but shall not include punitive damages.
17d. Punitive Damages: Enter from item 17a, the amount of punitive damages intended to punish or deter willful, wanton or malicious misconduct.
18. Loss Adjustment Expense Paid to Defense Counsel: Enter loss adjustment expense paid by you to defense counsel for this defendant.
19. All Other Allocated Loss Adjustment Expense Paid by You: Enter all allocated loss adjustment expense paid by you for this defendant. Include filing fees, telephone charges, photocopy fees, expenses of defense counsel, etc.
For questions 20 through 24, actual amounts should be reported, if unknown, report estimated amounts. If estimated amounts are reported, please indicate accordingly.
20. Injured Person’s Incurred Medical Expense: Enter amount of incurred medical expense from date of injury to date of closure.
21. Injured Person’s Anticipated Future Medical Expense: Enter total future medical expense if it appears the claimant will incur expenses in the future.
22. Injured Person’s Incurred Wage Loss: Enter amount of wage loss from date of injury to date of closure.
23. Injured Person’s Anticipated Future Wage Loss: Enter total future wage loss if it appears the claimant will incur wage loss in the future.
24. Injured Person’s Other Expenses: Enter amount of incurred plus future expense for substitute services and all other expense. Include funeral expenses here.
25. Total Amount Allocated for Future Periodic Payments (For All Defendants): If a reserve annuity, trust fund or similar mechanism was established to provide future periodic payments, enter the total amount thereof.
26a-d. Contact Information