What is Considered a Claim?

Most practitioners are highly aware of the importance of maintaining medical malpractice insurance coverage to protect themselves financially in the event of a malpractice claim. However, practitioners are less aware of the administrative claims they could face.

In addition to the risk of a malpractice claim, administrative claims can be just as devasting. Any claim, regardless of whether it is malpractice or administrative, can seriously impact your ability to continue practicing and has the potential to damage your career and your finances significantly.

Defining a Claim

There are malpractice claims and administrative claims. Administrative claims and malpractice claims differ, but they are all claims, nonetheless. Malpractice insurance provides defense and indemnity for liability actions while administrative defense coverage (ADC) provides defense for actions brought against you by governing bodies that control your ability to practice, such as licensing boards, hospitals, and third-party billers. We include ADC in all PICA policies ($100,000 per policy period and in the aggregate) to protect you from both types of allegations that could be brought against you.

It’s also important to note that a claim does not have to result in a trial verdict, settlement, or other significant payout to still be considered a claim. As the insured doctor, while you may not have done anything wrong, all claims have costs associated with resolving them. 

Malpractice Liability Allegations vs. Administrative Allegations

For a malpractice claim, an alleged injured party (the plaintiff) can seek compensation from the alleged wrongdoer (the defendant) if the plaintiff can establish the following:

• A duty was owed by the defendant to the plaintiff;
• A breach of that duty occurred; and
• The breach proximately caused demonstrable damage to the plaintiff.

When applied to medical professional liability claims, the three elements to be established become the following:

• There must be a verifiable doctor-patient relationship (duty owed);
• Negligence, in the form of a departure from acceptable medical standards (breach of duty); and
• The plaintiff must have suffered damage that was proximately caused by the doctor’s negligence (proximate cause).

On the other hand, administrative claims are different in nature from malpractice claims, and can include:

• Actions by state licensing boards
• Hospital peer review actions or attempts to restrict or revoke privileges
• MCO de-certification or contract terminations
• Actions brought by government payers such as Medicare or Medicaid
• Investigations involving billing and coding practices
• Meaningful Use audits

Both malpractice and administrative claims count toward your claim history, your practice profile, and potentially your policy premium. And both types of claims have significant costs associated with defending them. This is why it’s important to maintain a malpractice insurance policy that includes administrative defense coverage.

If you’re a current PICA policyholder and you’re curious about your claim history, we can provide you with a loss run report – request one here or contact your agent. If you are not currently insured with PICA, take a moment to see how we protect our podiatrists from all types of allegations. Fill out our online form to receive a free, no-obligation quote.

The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. In the event any of the information presented conflicts with the terms and conditions of any policy of insurance offered by ProAssurance Insurance Company of America, the terms and conditions of the actual policy will apply. All information contained on the blog is subject to change.