What does it take to succeed with healthcare claims?

Paul Lucas [00:00:14]

Hello everyone and welcome to Insurance Business TV as we zoom in on the healthcare claim space in association with Tokio Marine HCC- Cyber and Professional Lines Group. In this edition, we’re going to learn more about the firm’s allied medical appetite with a detailed overview of its medical spa and non-emergency medical transport classes. And beyond that, we’re also going to gain insights into its inhouse claims team and its low loss frequency. Joining us from Tokio Marine HCC- Cyber and Professional Lines Group we have Eric Isaacson, Underwriting Manager, Allied Medical Social Services and SMML. Margaret Michelini, Senior Underwriter, Allied Medical Social Services, and SMML. And Susan Papacostas, Claims Attorney. So welcome everyone. And to kick us off, Eric, I’m going to put the spotlights on you. Can you tell us a little bit more about your allied medical product?

Eric Issacson [00:01:19]

Of course, our allied medical product is intended to provide comprehensive coverage for a wide range of allied and ancillary healthcare providers and facilities. We offer professional liability and a claims made basis and can package general liability on a claims made or occurrence basis. We have many coverage enhancements we can offer which either erode the PL or the GL limits, we can offer sexual misconduct, med defence, which is our billing errors fraud and abuse coverage EMD employee benefits liability, hired an auto Dotto among many others. Many of our competitors endorse on coverage for independent contractors are formed naturally affords coverage to both ICs and employees that meet our definition of insured. Our definition is quite broad, we can offer up to two mil formal limits on certain classes and in certain territories. But one little one mil three mil limits is in fact, our standard offering.

Paul Lucas [00:02:17]

And this is something you’re offering in all states.

Eric Issacson [00:02:21]

We are not writing in New York, Alaska, Louisiana, Pennsylvania, or Washington.

Paul Lucas [00:02:28]

Okay, well, let’s delve into the risk elements if you don’t mind, RH or other certain types of risk, first of all, that you do not

Eric Issacson [00:02:36]

like to see. Sure we don’t like to see hospitals, physicians, physician groups, clinical trials, nursing homes, long-term care facilities, services and correctional facilities, medical marijuana, managed care organizations and health care consultants.

Paul Lucas [00:02:56]

Yeah, let’s flip things around a bit as well. What are the top classes that you’re hitting on?

Eric Issacson [00:03:03]

Sure, historically, we’ve done quite well in home health, hospice care, physical speech, occupational therapy clinics. More recently, we’re seeing a ton of non-emergency medical transportation, and medical spas, which Margie will touch on in a moment, as well as inpatient drug and alcohol rehab facilities with detox.

Paul Lucas [00:03:23]

And I imagine there are some insurance professionals out there brokers in particular, of course, who are looking to persuade their clients that they do need this coverage. So just explain to us why to health care entities and ancillary providers need professional liability coverage, and of course, sometimes general liability as well.

Eric Issacson [00:03:43]

Yeah, that’s a great question, to protect themselves from claims arising from negligence and providing professional services, from a general liability standpoint to protect themselves through common bodily injury, slip and falls in waiting rooms, healthcare entities, and ancillary providers provide a professional service that benefit many of us, and they need insurance in place to practice.

Paul Lucas [00:04:08]

Yeah, makes a lot of sense. I think I’ve put you in the spotlight long enough. Eric. Let me move across to Susan. Now, Susan, just give us a little bit of insight into the claims process here.

Susan Papacostas [00:04:20]

Sure. Well, the claims process that took Tokio Marine is basically two pronged internally. The key priority is to support the underwriting process. We want to give feedback on the insurance themselves, you know, we have direct contact there. And so that sometimes is important information for the underwriting team. We also give feedback on the interpretation of the policy language itself and how it’s really being viewed in the field. And then third, and this doesn’t happen that often year but also to make sure they’re aware of any problematic claims that have come in. But all of this information is meant to aid them in assessing the risk in any particular insured and overall in the underwriting process, and we have direct contact with the insurance when a claim comes in, and the key focus there is to make sure they’re aware of the claims process, always what they can expect next. And often when a claim comes in the insurance are nervous, it can be their first time. And it’s our job to make sure the entire claims process is smooth, and as uneventful as it can be for them. And part of that is also assigning our panel counsel who are experts in any given field, that the insured work then so that’s basically it’s two pronged for our, the internal stakeholders and externally for our clients.

Paul Lucas [00:05:45]

You touched on the underwriting side of things there. So I think it’s only fair that we bring in our senior underwriter as well. Margaret, so what do you look for as an underwriter when reviewing a medical spa submission?

Margaret Michelini [00:05:59]

Sure, right now, there are so many individuals looking to go today, and medical spas for various different reasons. From facials at a day spa, to Botox at a medical spa. These facilities have repeat customers for these types of services, and new day and medical spas are opening all the time all over the world. We as underwriters are seeing a lot more of these submissions, and at the Medical spas, we are seeing a lot of new procedures, which makes us put our underwriting hats and drill down on the new service provided, we look for who specifically as a provider is performing the procedure, and what type of experience they have. Also, the operation manual is very important. And not all medical spas have done. This manual makes an underwriter feel much more comfortable with the risks and shows the insurer cares for their patients. We want to make sure we look to ensure medical spas that put patient’s health and safety over profit.

Paul Lucas [00:07:05]

Okay, so that’s what you’re looking for. But Susan, maybe you can just shed a little bit more light for us on a typical medical spa claim.

Susan Papacostas [00:07:13]

Sure, I mean, the bulk of what we’re seeing in in in this arena are claims involving laser treatments. And often these treatments are a series of appointments that the client has with the insured. And at one of them something in their opinion goes wrong, right. So often these kinds of claims start with a simple request for a refund of whatever fee the claimant has paid. And the insured will very rightly pushback because they have as Margie mentioned, they have consent form sign they have form sign saying that the client was aware of all the risks. So that can then get contentious, and they sometimes escalate. And when that happens, it ends up in our lap. And what we really need is quick interaction with the insured, we want to know who provided the treatment, we want to interview that person. And if it’s escalated to the point where the the claimant has obtained legal representation, then we want to quickly do the same for our insured and assign as I mentioned before our expert panel cancel. But one of the keys in this area is to interview the people involved as quickly as possible, because these are our insurance treat hundreds and hundreds of patients you know all the time and you want to get to them before their memories fail or anything has changed. And because the underwriting is so strong, they’re almost always going to have all the documentation we need in place. And that’s that’s really what we’re seeing. And that’s really how it would be him.

Paul Lucas [00:08:46]

Yeah, if you don’t mind, I’d just like to touch on a controversial subject for a moment if I can. I’m just interested. Margaret, do you as underwriters have an appetite for any of the weight loss drugs that we’ve seen the news?

Margaret Michelini [00:09:00]

Yes, when it comes to all the weight loss drugs we are seeing in the news, we do have the ability to cover them. We’d like to see that they are FDA approved and the appropriate provider is prescribing them correctly. Our form has a natural FDA exclusion, but we have an endorsement we can use that amends our FDA exclusion, affording coverage to a procedure or a drug that is being used as off label when it makes sense to do so.

Paul Lucas [00:09:29]

And when you’re sort of looking as underwriters reviewing gait a non emergency medical transportation submission, what exactly are you looking for the

Margaret Michelini [00:09:38]

we look at the type of transportation that is provided and the type of clients medical condition of the clients that are being transported. We are covering transportation services for clients that cannot transport themselves due to a physical or mental condition. Not a medical transport is for clients that have a medical condition. event itself transports Patient example would be transport to and from doctor’s appointments. We usually see drivers on staff for this subclass, when including loading and unloading coverage, we require the insurer to provide a loading and unloading procedures they have in place. We also require $1 million separate auto coverage to be placed auto coverage to match the PLT limits we are providing. So that’s what you

Paul Lucas [00:10:28]

can offer. But Susan, can you tell us a little bit more about a claim in that space?

Susan Papacostas [00:10:33]

Sure. I mean, the most frequent claims at this point are a loading and unloading claims. And as as Margie explained, you know, we provide that coverage by endorsement. The it’s, it makes sense, right? Because it just has to do with the individuals and how they’re actually either physically moved from their home or from their doctor’s office into the transport vehicle, are oftentimes how they are sort of locked into place in the vehicle, is the wheelchair properly clipped? Are they properly secured in the wheelchair or on the stretcher. And the key to getting these claims right when they come out is again, to get in touch with the insured as quickly as possible, make sure they have an incident report on file, which has their side of the story. Because it’s often you know, he said, she said or he said he said as to what exactly happened in the vehicle and interview the driver and make sure that all of the stories and points line up and also, if there are witnesses to these things, because unlike with the medic spar there often are these the these sorts of in there can be an auto accident with other witnesses, there can be an issue with the person being unloaded from the vehicle at the doctor’s office where nurses would be meeting them. So if there’s any witnesses to exactly what happened, it’s critical to get them quickly as well, because again, memory fails and people forget or miss remember things. And again, if it escalates which it often does in this particular space, we have our expert panel counsel that are ready to step in, in every state where we where we write this business. So that’s really what we’re seeing and how it’s handled. And again, our job is always to make sure our insureds are taken care of feel that the process has been explained to them. They know what’s coming next. That’s always the question. Okay, what’s next? And it’s our job to answer them.

Paul Lucas [00:12:28]

Right. And I would just like to throw out one final question. So to wrap things up, Eric, if you don’t mind, I’ll bring you back in. Just tell me a little bit about as an underwriter, what you’re looking for in a submission and why?

Eric Issacson [00:12:43]

Sure, as underwriters, we looked for complete submissions, meaning a full form application, including rating basis, risk management, claims questions, type of services provided, where they’re provided,

resume expiring deck page loss runs of current coverages in force, and a clear definition of professional services. Risk management is also really important to us and makes us feel more comfortable about the overall operation.

Paul Lucas [00:13:12]

And some really fantastic insights. Thank you very much indeed. I’m sure a lot of our brokers are going to be reaching out on the back of this. My thanks again to Eric


Appreciate. The opportunity to Margaret

Margaret Michelini [00:13:26]

Thank you for having me.

Paul Lucas [00:13:27]

And to Susan

Susan Papacostas [00:13:29]

baseball. It’s it’s been a pleasure. And

Paul Lucas [00:13:32]

thanks, of course to you at home, in the office or wherever you may be. We will see you next time right here on Insurance Business TV.

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