Illinois Administrative Code › Title 50 - INSURANCE › Part 928 - MEDICAL PROFESSIONAL LIABILITY DATABASE › Exhibit B - Illinois Medical Professional Liability Insurance Uniform Claims Report - Reporting Instructions

Current through Register Vol. 48, No. 28, July 12, 2024
As required by Section 155.19 of the Insurance Code [
				215
				ILCS 5/155.19 ] and 50 Ill. Adm. Code 928:
1. File all opened, closed, re-opened, and
			 re-closed medical professional liability insurance claims and lawsuits,
			 including any updates, with the DOI on a quarterly basis. For closed claims,
			 include claims closed without payment. Insurance claim means a formal or
			 written demand for compensation under a medical professional liability
			 insurance policy relating to allegations of liability on the part of one or
			 more providers for any act, error or omission in the rendering of, or failure
			 to render, medical services for medically related injuries. Insurance claim
			 includes any instance for which benefits or compensation are payable or
			 eligible to be paid under any coverage under the policy. Lawsuit means a
			 complaint filed in any court in this State alleging liability on the part of
			 one or more providers for any act, error or omission in the rendering of, or
			 failure to render, medical services for medically related injuries.
2. File separate reports for each defendant
			 you insure. Each filing of a claim or lawsuit report shall be identified with a
			 unique claim number. If more than one defendant/insured is associated with an
			 incident, a unique claim number is required for each defendant/insured. If more
			 than one claimant/injured party is associated with an incident, a unique claim
			 number is required for each claimant/injured party. When there are multiple
			 associated claims/lawsuits, report the incident identifier in the other claims
			 information section.
3. RESPONSES
			 TO ALL FIELDS ARE REQUIRED. For open claim reports, complete Insurer
			 Information through Contact Person Information. When updating reports, any
			 information may be updated. For closed claim reports, all fields are required.
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Insurer Information
1a. Insurer Name (not group name) (Maximum =
			 40 characters).
1b. Insurer 9-digit
			 FEIN. Entities without a Federal Employer Identification Number (FEIN), contact
			 the DOI for assigned number.
Initial Claim Information
2a. Claim ID. For each open claim report,
			 assign a distinguishing claim number sufficient to enable the Department of
			 Insurance (DOI) to track a particular claim over a period of years. This claim
			 number should consist of a unique sequence of letters and/or numbers. Once a
			 claim number has been assigned, it should not be repeated for any future claim.
			 One claim record should be reported for each named individual or entity
			 formally alleged to have contributed to an injury or grievance and from whom a
			 malpractice payment is being sought. On re-opened claims, use the same claim
			 number as the original claim file that is being re-opened.
2b. Date of Principal or Alleged Injury
			 (MM/DD/YYYY). Report the date of the earliest alleged error or omission that
			 was the first necessary if not sufficient cause of the alleged medical
			 injury.
2c. Date Incident First
			 Reported to Insurer (MM/DD/YYYY). Date of alleged injury first reported to the
			 insurer.
2d. Date Claim Opened by
			 Insurer (MM/DD/YYYY).
2e. Date
			 Claim Re-Opened by Insurer (MM/DD/YYYY).
2f. Date of Original Closure (MM/DD/YYYY).
			 Only applicable if claim was re-opened.
2g. Date of Final Closure (MM/DD/YYYY). The
			 date of final disposition or settlement of a claim. Payments for defense costs
			 or indemnity may occur after the date of closure (as in a structured
			 settlement).
Insured Information
3a. Profession or Business Code. (1)
			 Physician or Surgeon*; (2) Hospital; (3) Nurse*; (4) Nursing Home; (5)
			 Dentist*; (6) Pharmacy; (7) Optometrist*; (8) Chiropractor*; (9)
			 Podiatrist/Chiropodist*; (10) Clinic/Corporation; (11) Other* - Employee
			 (Maximum = 25 characters). A code with an asterisk (*) requires a "Type of
			 Practice Code" as well.
3b. Type of
			 Practice Code. (1) Institutional, including Academic; (2) Professional
			 Corporation, Partnership, or Group; (3) Self-Employed; (4) Hospital; (5)
			 Nursing Home; (6) All Other Employees; (7) Intern or Resident.
3c. Insured's Name, including suffix such as
			 MD, DO, etc.
3d. Insured's Illinois
			 License Number. Enter FEIN for clinics and corporations.
3e. Medical Specialty Codes. Select the most
			 relevant specialty code from the following table.
Code
Description
Physician Specialties
01
Allergy and Immunology
03
Aerospace Medicine
05
Anesthesiology
10
Cardiovascular Diseases
13
Child Psychiatry
20
Dermatology
23
Diagnostic Radiology
25
Emergency Medicine
29
Forensic Pathology
30
Gastroenterology
33
General/Family Practice
35
General Preventive Medicine
37
Hospitalist
39
Internal Medicine
40
Neurology
43
Neurology, Clinical Neurophysiology
45
Nuclear Medicine
50
Obstetrics & Gynecology
53
Occupational Medicine
55
Ophthalmology
59
Otolaryngology
60
Pediatrics
63
Psychiatry
65
Public Health
67
Clinical Pharmacology
69
Physical Medicine & Rehabilitation
70
Pulmonary Diseases
73
Anatomic/Clinical Pathology
75
Radiology
76
Radiation Oncology
80
Colon & Rectal Surgery
81
General Surgery
82
Neurological Surgery
83
Orthopedic Surgery
84
Plastic Surgery
85
Thoracic Surgery
86
Urological Surgery
98
Other Specialty - not classified
99
Unspecified
Dental Specialties
D1
General Dentistry (no specialty)
D2
Dental: Public Health
D3
Endodontics
D4
Oral and Maxillofacial Surgery
D5
Oral and Maxillofacial Pathology, Orthodontics and
						  Dentofacial
D6
Orthopedics
D7
Pediatric Dentistry
D8
Periodontics
D9
Prosthodontics
DA
Oral and Maxillofacial Radiology
DB
Unknown
3f.
			 County of Insured's Principal Place of Practice for Rating Purposes.
3g. Policy Limits Available, Primary
			 Coverage. Policy limits available for the claim being reported under the
			 insured's primary coverage.
3h.
			 Policy Limits Available, Excess Coverage. Policy limits available for the claim
			 being reported under the insured's excess coverage.
Place of Injury Information
4a. Place Where Alleged Injury Occurred Code.
			 Enter only one. (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*; (U)
			 Unknown*; (X) Other* - describe place (Maximum = 25 characters).
A code with an asterisk (*) requires a "Location Within
				Institution Code" as well.
4b. Location Within Institution Code.(1)
			 Patient's Room; (2) Labor/Delivery Room; (3) Operating Suite; (4) Recovery
			 Room; (5) Critical Care Unit; (6) Special Procedure Room; (7) Nursery; (8)
			 Radiology; (9) Physical Therapy Department; (U) Unknown; (X) Other - describe
			 (Maximum = 25 characters).
4c.
			 County Where Alleged Injury Occurred. Full name of the county in which the
			 injury is alleged to have occurred.
Injured Person Information
5a. Injured Person's Name.
5b. Injured Person's Gender. M F
5c. Injured Person's Age. Enter age of
			 injured person at the date of injury.
Other Claim Information
6a. Total Number of Defendants. Enter total
			 number of persons or corporations that you insure that are involved in the
			 incident relating to this claim.
6b. Incident Identifier. Each reporting
			 entity should assign a unique numeric identifier for each incident or
			 occurrence. An occurrence is an event or series of events leading to an
			 allegation of malpractice, and that may involve allegations against multiple
			 individuals and entities. An occurrence is defined causally and may or may not
			 be constrained in time. For example, multiple failures to diagnose a given
			 illness may occur over a period of years. Such a series of events would be
			 considered a single occurrence. Each claim submitted for providers involved in
			 a single occurrence should be assigned the same incident identifier.
Contact Person Information
7a. Name of Person Responsible for Preparing
			 this Report.
7b. Title of Person
			 Responsible for Preparing this Report.
7c. Contact Person Name (if different than
			 Name of Person Responsible for Preparing this Report).
7d. Contact Person Telephone
			 Number.
7e. Contact Person Email
			 Address.
Plaintiff Attorney Information
8a. Plaintiff Attorney's Name or Name of Law
			 Firm.
8b. Plaintiff Attorney's
			 Office City.
8c. Plaintiff's
			 Attorney's Office State.
Claim Data Information
9a. Nature and Substance of Claim. Give
			 complete description of all actions and circumstances causing the claim,
			 including allegations made by claimant. (Maximum = 250 characters)
9b. Allegation Codes Related to Claim. Enter
			 as many codes as needed. Use DOI 3-digit codes listed below. (1) Diagnosis
			 Related; (2) Anesthesia Related; (3) Surgery Related; (4) Medication Related;
			 (5) Intravenous and Blood Products Related; (6) Obstetrics Related; (7)
			 Treatment Related; (8) Monitoring Related; (9) Biomedical Equipment/Product
			 Medication Related; (10) Miscellaneous Related.
DOI 3-digit Allegation Code choices:
Diagnosis-Related
010 - Failure to Diagnose (e.g., concluding that
						  patient has no disease or condition worthy of follow-up or
						  observation)
020 - Wrong Diagnosis or Misdiagnosis (e.g., original
						  diagnosis is incorrect)
030 - Improper Performance of Test
040 - Unnecessary Diagnostic Test
050 - Delay in Diagnosis
060 - Failure to Obtain Consent/Lack of Informed
						  Consent
070 - Diagnosis Related - Not Otherwise
						  Classified
Anesthesia-Related
110 - Failure to Complete Patient Assessment
120 - Failure to Monitor
130 - Failure to Test Equipment
140 - Improper Choice of Anesthesia Agent or
						  Equipment
150 - Improper Technique/Induction
160 - Improper Equipment Use
170 - Improper Intubation
180 - Improper Positioning
185 - Failure to Obtain Consent/Lack of Informed
						  Consent
190 - Anesthesia Related - Not Otherwise
						  Classified
Surgery-Related
210 - Failure to Perform Surgery
220 - Improper Positioning
230 - Retained Foreign Body
240 - Wrong Body Part
250 - Improper Performance of Surgery
260 - Unnecessary Surgery
270 - Delay in Surgery
280 - Improper Management of Surgical Patient
285 - Failure to Obtain Consent/Lack of Informed
						  Consent
290 - Surgery Related - Not Otherwise
						  Classified
Medication-Related
305 - Failure to Order Appropriate
						  Medication
310 - Wrong Medication Ordered
315 - Wrong Dosage Ordered of Correct Medication
320 - Failure to Instruct on Medication
325 - Improper Management of Medication Regimen
330 - Failure to Obtain Consent/Lack of Informed
						  Consent
340 - Medication Error - Not Otherwise
						  Classified
350 - Failure to Medicate
355 - Wrong Medication Administered
360 - Wrong Dosage Administered
365 - Wrong Patient
370 - Wrong Route
380 - Improper Technique/Induction
390 - Medication Administration Related - Not Otherwise
						  Classified
Intravenous & Blood Products-Related
410 - Failure to Monitor
420 - Wrong Solution
430- Improper Performance
440 - I.V. Related - Not Otherwise Classified
450 - Failure to Ensure Contamination Free
460 - Wrong Type
470 - Improper Administration
480 - Failure to Obtain Consent/Lack of Informed
						  Consent
490 - Blood Product Related - Not Otherwise
						  Classified
Obstetrics-Related
505 - Failure to Manage Pregnancy
510 - Improper Choice of Delivery Method
520 - Improperly Performed Vaginal Delivery
530 - Improperly Performed C-Section
540 - Delay in Delivery (Induction or Surgery)
550 - Failure to Obtain Consent/Lack of Informed
						  Consent
555 - Improperly Managed Labor - Not Otherwise
						  Classified
560 - Delay in Treatment of Fetal Distress (i.e.,
						  identified but treated in untimely manner)
570 - Retained Foreign Body/Vaginal/Uterine
575 - Abandonment
580 - Wrongful Life/Birth
590 - Obstetrics Related - Not Otherwise
						  Classified
Treatment-Related
610 - Failure to Treat
620 - Wrong Treatment/Procedure Performed
630 - Failure to Instruct Patient on Self-Care
640 - Improper Performance of Treatment/Practice
650 - Improper Management of Course of Treatment
660 - Unnecessary Treatment
665 - Delay in Treatment
670 - Premature End of Treatment (Also
						  Abandonment)
675 - Failure to Supervise Treatment/Procedure
680 - Failure to Obtain Consent/Lack of Informed
						  Consent
685 - Failure to Refer or Seek Consultation
690 - Treatment Related - Not Otherwise
						  Classified
Monitoring-Related
710 - Failure to Monitor
720 - Failure to Respond to Patient
730 - Failure to Report on Patient Condition
790 - Monitoring Related - Not Otherwise
						  Classified
Biomedical Equipment/Product-Related
810 - Failure to Inspect/Monitor
820 - Improper Maintenance
830 - Improper Use
840 - Failure to Respond to Warning
850 - Failure to Instruct Patient on Use of
						  Equipment/Product
860 - Malfunction/Failure
890 - Biomedical Equipment/Product-Related - Not
						  Otherwise Classified
Miscellaneous-Related
920 - Failure to Protect Third Parties (e.g., failure
						  to warn/protect from violent patient behavior)
930 - Breach of Confidentiality/Privacy
940 - Failure to Maintain Appropriate Infection
						  Control
950 - Failure to Follow Institutional Policy or
						  Procedure
960 - Other (Provide Detailed Description)
990 - Failure to Review Providing
						  Performance
9c.
			 Severity of Injury Code. Select only one - Select code for principal injury if
			 several injuries are involved.
Temporary:
1. Emotional Only (e.g., fright, no physical
						  damage)
2. Insignificant (e.g., lacerations, contusions, minor
						  scars, rash; no delay)
3. Minor (e.g., infections, misset fracture, fall in
						  hospital; recovery delayed)
4. Major (e.g., burns, surgical material left, drug
						  side effect, brain damage; recovery delayed)
Permanent:
5. Minor (e.g., loss of fingers, loss or damage to
						  organs; includes non-disabling injuries)
6. Significant (e.g., deafness, loss of limb, loss of
						  eye, loss of one kidney or lung)
7. Major (e.g., paraplegia, blindness, loss of two
						  limbs, brain damage)
8. Grave (e.g., quadriplegia, severe brain damage,
						  lifelong care or fatal prognosis)
9. Death
9d.
			 Claim Disposition Code. Enter code representing the final disposition of the
			 claim. (1) Settled by Parties*; (2) Disposed of by a Court**; (3) Disposed of
			 by Binding Arbitration***; (4) Suit Abandoned****; (5) Claim Abandoned.
A code with an (*) requires a "Settlement Code" as
				well.
A code with an (**) requires "Court Information" to
				be completed as well.
A code with an (***) requires a "Binding Arbitration
				Code" as well.
A code with an (****) requires a "County of Circuit
				Court" and "Docket Number" as well.
9e. 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 or Decision/Award;
			 (5) After Judgment or Decision but Before Appeal; (6) During Appeal; (7) After
			 Appeal; (8) As a result of Review Panel or Non-Binding Arbitration**; (9) As a
			 Result of Mediation; (10) As a Result of High/Low Settlement***.
A code with an (**) requires a "Review Panel or
				Non-Binding Arbitration Code" as well.
A code with an (***) requires all applicable "Court
				Information" except "Court Code".
9f. Review Panel or Non-Binding Arbitration
			 Code. (1) Finding for Plaintiff; (2) Finding for Defendant.
9g. Binding Arbitration Code (1) Award for
			 Plaintiff; (2) Award for Defendant.
Court Information
10a. Court Code. (1) Directed Verdict for
			 Plaintiff; (2) Directed 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) Decision for Plaintiff on Appeal; (8) Decision for
			 Defendant on Appeal; (9) Voluntary Dismissal; (10) Involuntary Dismissal; (11)
			 All Other Actions.
10b. County of
			 Circuit Court. County of Circuit Court where lawsuit occurred.
10c. Docket Number.
10d. Date of Award. (MM/DD/YYYY)
10e. Was the Circuit Court decision appealed?
			 Y or N If "Y", Describe the Result of the Appeal. (Maximum = 25
			 characters)
10f. Describe any Other
			 Post Trial Motions. (Maximum = 25 characters)
10g. Economic Damages. Amount of economic
			 damages awarded by the court. (whole dollar amounts only)
10h. Non-economic Damages. Amount of
			 non-economic damages awarded by the court. (whole dollar amounts
			 only)
10i. Liability Doctrine.
			 Indicate whether liability was governed by the doctrine of joint and several
			 liability (J) or whether liability was separate (S).
Claim Payment Information
11a. Total Direct Indemnity Paid/Payable by
			 You Under this Policy on Behalf of this Insured/Defendant. (whole dollar
			 amounts only)
11b. Economic
			 Damages. If 9d Claim Disposition Code is (2) Disposed of by a Court, enter the
			 amount that was paid/payable by you for economic damages, as indicated by the
			 court award. This amount plus 11c. Non-Economic Damages must equal amount
			 reported in 11a. Total Direct Indemnity Paid/Payable by You Under this Policy
			 on Behalf of this Insured/Defendant. (whole dollar amounts only)
11c. Non-Economic Damages. If 9d Claim
			 Disposition Code is (2) Disposed of by a Court, enter amount that was
			 paid/payable by you for non-economic damages, as indicated by the court award.
			 This amount plus 11b. Economic Damages must equal amount reported in 11a. Total
			 Direct Indemnity Paid/Payable by You Under this Policy on Behalf of this
			 Insured/Defendant. (whole dollar amounts only)
11d. Direct Loss Adjustment Expense
			 Paid/Payable by You under this Policy to Defense Counsel. (whole dollar amounts
			 only)
11e. All Other Allocated Loss
			 Adjustment Expenses Paid/Payable by You for this Insured/Defendant for this
			 claim, including filing fees, telephone charges, photocopy fees, expenses of
			 defense counsel, etc. (whole dollar amounts only)
11f. Direct Indemnity Paid/Payable by You
			 Under All Policies for this Insured/Defendant. (whole dollar amounts
			 only)
11g. Other Indemnity Paid by
			 or on Behalf of this Insured/Defendant. (whole dollar amounts only)
D) Deductibles paid by insured/defendant for this
				claim under this policy;
E) Indemnity paid under any excess limits policy
				issued by you;
R) Amount paid by insured/defendant under
				self-insured retention;
S) Amount you paid above any stop loss limit.
11h. Claimed Medical
			 Expense. Amount of medical expense claimed by the plaintiff/injured party.
			 (whole dollar amounts only)
11i.
			 Claimed Wage Loss. Amount of wage loss claimed by the plaintiff/injured party.
			 (whole dollar amounts only)
11j.
			 Trial Type. If trial was started, indicate whether it was a bench trial (B) or
			 jury trial (J).