Notifying your insurer of a possible claim

ADA members have all recently renewed their membership and most have simultaneously renewed their Professional Indemnity cover. It is recognised that dentists whether in private or public practice, often lack time to do more than tick the right box and send off the cheque. Your obligations to your indemnifier do not stop at paying the premium however.

It has become apparent to the ADA Branches and Guild Insurance Limited (GIL) that members often have trouble recognising circumstances that oblige them to notify Guild (through their ADA Branch) that they may need to make a claim under the terms of their policy.

There are certain obligations that dentists owe their Indemnity provider, such as notifying them in the event of any potential legal liability, incidents or claims. There are also benefits such as access to legal advice that are often not used because dentists are not aware of the protection available in the insurance policy. These may have been read and understood when the policy was taken out after graduation but have been forgotten or overlooked because there has been no need to call on them in the intervening time.

This article seeks to clarify what those circumstances are so that GIL, through the local ADA Branch receives early notifications, to enable members to access the help they need in a timely and effective manner. The events of 2009-10 associated with Medicare audits in particular have shown, there is a real need for dentists to carefully consider their rights and responsibilities as policy holders

The insurance cover offered by GIL is multi-faceted, and so there are a wide range of circumstances that should be recognised as trigger events for contact with the ADA Branch and GIL. The cover provided to ADA members by GIL is a combined liabilities cover, and includes:

  • Professional indemnity protection
  • Public liability protection
  • Products liability protection
  • Legal fees cover

For example, under the Legal Fees cover, an Insured Event is defined as;

“A fact situation or circumstance which:

  • arises out of the operation of the Dental Practice; and
  • results in or has the potential to result in criminal prosecution, a coronial inquiry, a de-recognition inquiry by a health benefit insurer or the pursuit of disciplinary proceedings by a legally constituted industry board, committee or the like, or results in or has the potential to result in the defending of any claim or legal proceeding following a dispute with an employee, former employee or applicant for employment pursuant to any State or commonwealth Anti-Discrimination or Equal opportunity legislation.”

This means that Medicare Australia audits, Health Fund investigations and audits, Professional Services Reviews and Dental Registration Board investigations and hearings (amongst other trigger events) are all notifiable to GIL through your ADA Branch.

Different triggers will apply under each of the forms of cover available, and to illustrate how wide a range of circumstances could be involved the table below has been developed, based on actual dental claims experience.

In managing any of the following incidents, a professional approach and timely notification to the ADA and GIL mean that the matter can be handled with the least amount of stress and anxiety to the dentist, with access to both dental and legal professionals being available if required. Often the immediate reaction to an incident, whether a complaint or an adverse outcome can range from shock, anger, disappointment and often the feeling that you just want the problem to be solved. Consequently independent and helpful advice on how to approach the incident, together with possible solutions and case preparation if required, mean that the situation can be resolved in an efficient manner. In all instances, it is the management of the problem which needs close attention, and if handled correctly leads to the best outcome for all parties involved.

Professional Indemnity

Illustrative Incidents:

  • A patient swallows a bur head which broke while you were preparing a cavity.
  • On preparing a root canal, you perforated the apex and the sinus.
  • After removing a third molar, the patient reported enduring numbness some weeks afterwards.
  • Endodontic treatment is commenced on the incorrect tooth.
  • You realise you have extracted the wrong tooth.
  • In response to you sending a notice about an overdue account, a patient indicates that they were not happy with the treatment and that they expect you to waive the fee.
  • A patient contacts the ADA asking whether the fee you charged is reasonable and the ADA contacts you to seek information about any problems you may have encountered.
  • A nearby practice contacts you to ask for transfer of a patient’s records and hints that the patient wasn’t happy with work you did for them 6 months ago.

Comments:

In all of these, the most important steps are:

  • Informed consent before the procedure if indicated.
  • Informing the patient about the incident when it occurs.
  • Recording the incident and patient discussions.
  • Referring the patient for appropriate follow up treatment or monitoring.
  • Contacting the ADA Branch to help submit an Initial Advice form to notify GIL that there is a potential claim and advice on how to handle the patient’s future management to avoid a notification if possible.
  • Discuss with the ADA advisor on how to proceed and possible approaches to reach a solution.
  • The ADA advisor will be able to inform you whether the incident should be notified to GIL.
  • In most cases the matter will be referred to GIL as a notification only, but with the potential to become a claim.
  • The use of the ADA mediation service if available may be suggested by GIL.

Public Liability

Illustrative Incidents:

  • A patient trips on the steps at the entrance to your practice and suffers cuts and bruising.
  • A patient bumps into your practice sign when parking in your car park, requiring a new sign to be installed.
  • While entering the surgery, an elderly patient slips on a wet floor and suffers a broken hip.

Comments:

  • Public Liability cover of $20 million forms part of your GIL cover. This covers accidental bodily injury or damage to property arising from your negligence.
  • Notification to GIL is required.

Products Liability

Illustrative Incidents:

  • Goods you sold to a patient were considered faulty and the patient alleges this caused them an injury.
  • Advice you provided about use of a home bleaching tray was considered the cause of soft tissue damage and the patient is seeking remedy.

Comments:

  • Covered under Products Liability ‘Civil liability for Goods Sold and Advice on Goods Sold’.
  • Notification to GIL is required.

Legal Fees

Illustrative Incidents:

  • Medicare Australia contacts the practice inviting the practitioner/s to respond to a questionnaire about rebates paid to them in relation to the Chronic Disease Dental Scheme.
  • HBA contacts the practice indicating that they intend to conduct an audit of treatment provided and accounts rendered for certain fund members.
  • The Chief Investigator at the Registration Board contacts the practice to advise that he will be visiting to interview the principal and staff about a patient complaint.
  • The Health Services / Complaints Commissioner contacts you to seek conciliation of a complaint by a patient.

Comments:

  • All of these circumstances are notifiable events and you are required under your GIL policy to contact GIL through the ADA to notify them as soon as possible after the event.
  • The matter will be recorded and notified for legal fees assistance and advice from the ADA will be provided.
  • If the matter is subsequently deemed to not have merit and is dismissed, with no adverse finding, GIL will remove the case from active files.
  • Your GIL policy is available for your protection and assistance. Focus is on early intervention.
  • None of these incidents should be handled without GIL notification and assistance.

If you need another copy of your Guild Insurance Policy, please contact Guild Insurance on 1800 810 213.

If you wish to discuss circumstances which might lead to a claim, which you have not previously notified to your insurer, contact your ADA Branch as soon as possible.

Dr Eryn Agnew
ADAVB Community Relations Officer and professional Consultant

Mr Garry Pearson
ADAVB CEO

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    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    .

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