Notifying Guild Insurance of a claim - your requirements

Imagine if… you are advised by AHPRA that a patient has complained about the treatment you provided, suggesting it was performed negligently. As you’re sure your treatment was appropriate, you immediately reply to AHPRA informing them of your version of events. Some time after you hear from AHPRA again stating that they still have questions about your treatment and will be investigating further.

Guild Insurance’s Liabilities policies state that as soon as you, as the policy holder, experience a claim made against you or an incident which could give rise to a claim, you are required to notify Guild. However, Guild has noticed a worrying trend where practitioners are responding to complaints on their own without first notifying Guild. This can have a number of consequences for these practitioners as they’re not receiving the support or guidance their insurance policy may entitle them to. It can also mean the policy holder is not adhering to the conditions of the insurance policy.

Possible scenarios

The following scenarios are some examples of when you should notify Guild Insurance:

  • If AHPRA has notified you of a complaint from a patient or other person and AHPRA has asked you to reply with your version of events.
  • If a private health insurer, or other funding provider such as Medicare, has requested access to your clinical records as evidence of billing practices.
  • If a solicitor or law firm representing a patient has requested access to your clinical records.
  • If a patient has complained directly to you or your practice with a formal demand for compensation or suggested they’ll make a notification to a regulatory body such as AHPRA.
  • Any other circumstance where you have an uneasy feeling about an incident or situation; when in doubt, notify!

When to notify Guild

Practitioners are sometimes unsure whether a matter is serious enough to warrant notifying their insurance company. There are some occasions where notifying an insurance company is a must, such as when replying to AHPRA following an allegation, when there is a request for patient records from a solicitor or funding provider or when there is an allegation of the patient suffering harm following treatment. However, when a patient complains directly to you, this is when you need to use your judgement. If the patient has simply informed you that they didn’t respond as hoped to treatment following their previous appointment yet doesn’t seem annoyed or demanding, then this may be a matter which can be sorted by you alone. Yet if you’re in doubt or concerned about the complaint or allegation from the patient, then you should notify Guild.

Will my premium go up if I notify Guild of a matter?

Guild’s premium pricing is influenced by a number of factors. Notifying Guild of an incident is unlikely to be the cause of a premium increase the following year. However, as detailed below, not notifying Guild may lead to further stress and complications. Therefore, the cost of the premium should not be a factor in deciding whether or not to notify Guild.

Consequences of not notifying Guild

Facing an allegation or investigation of any sort can be an extremely stressful situation for a practitioner. When a practitioner handles a matter themselves without the support of Guild, that stress is compounded as the practitioner will be dealing with a process they’re unfamiliar with.

Guild has seen many cases where a practitioner’s own response has either not provided the required information, or a response has been written in a way which is likely to inflame or escalate the situation. This usually leads to further investigations being conducted and Guild being notified after the investigation has begun, inhibiting Guild’s support and influence.

When a practitioner doesn’t notify Guild as soon as is reasonably possible of a claim made against them, they may be considered to not be complying with the conditions of the insurance policy. This can lead to cover under the policy being cancelled or the claim not being paid.

It’s also important to understand that a practitioner may leave themselves with out of pocket expenses by not notifying Guild at the beginning. This may occur if they engage their own legal counsel not approved by Guild and at a rate Guild believes to be exorbitant or if they have offered to settle a matter without Guild’s consent.

The staff at Guild Insurance have a great deal of experience and expertise in managing allegations and investigations and are well aware of what is required when responding to them. For this reason, it’s of benefit to everyone involved to notify Guild immediately and be sure the necessary support is provided and process is followed from the start.

How to contact Guild Insurance

To notify Guild of an incident, and therefore make a claim against your insurance policy, either call Guild on 1800 810 213 or go to guildinsurance.com.au/claims

Disclaimer

Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791. This article contains information of a general nature only, and is not intended to constitute the provision of legal advice. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them. RHQ21092 Notifying Guild Insurance of a claim 01/2019

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