Commonwealth of Massachusetts
  Board of Registration in Medicine
  200 Harvard Mill Square, Suite 330
  Wakefield, MA 01880
  (781) 876-8200
  (781) 876-8395 (TTY)
  Hours M-F; 8:45 a.m. to 5:00 p.m.


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PROFESSIONAL LIABILITY INSURANCE REPORT OF CLOSED CLAIM

Instructions

A claim is any demand for damages (whether or not for a specified amount, and whether or not a lawsuit has been filed) for personal injuries alleged to have been caused by error, omission or negligence in the performance of professional services, communicated orally or in writing to the reporting insurer or risk management organization.

Pursuant to G.L. chapter 112 section 5C, Form PLICC must be filed with the Board within thirty (30) days after any of the following events:

1. a final judgment
2. a settlement, or
3. a final disposition not resulting in payment on behalf of the insured

For the purposes of determining the date that triggers this filing requirement, please use the following guidelines:

• Final judgment – the date of the judgment entered by a trial court. If the judgment is appealed and any information in the original report is no longer correct, a second form must be filed within thirty (30) days of the decision of the appeals court.



• Settlement – The earlier of:
  1. the date of the settlement agreement
  2. the date of the release and waiver signed with respect to the licensee reported on the form, or
  3. the date that the settlement agreement or other final document was filed with the trial court.
  
  
• Final disposition – if a lawsuit was filed, the date of final judgment (as defined above), or the date any motion to dismiss was granted or notice of dismissal was filed. If no lawsuit was involved, the earlier of:
  1. the date that the reporting insurer, according to its customary practice, closed its file with respect to the claim against the subject licensee, or
  2. the date of any waiver and release signed with respect to that licensee.

Specific Instructions

Physician Information:

• Name – the licensed Massachusetts physician [i.e., an M.D., D.O. or the holder of a limited license (e.g. intern, resident, house officer)] against whom the claim was brought or filed. If more than one physician was involved in the claim, a separate Form PLICC must be filed for each such insured physician.
• Address – the primary office address of the subject physician. If the physician has no office, then supply the address of the hospital or other health care facility with which the physician is primarily associated.

Claim Information

• Date When Claim Arose (Incident Date) – the date of the event that gave rise to the claim. If there was no single event, or if the injury occurred over a period of time, identify the probable time period during which the event(s) occurred.
• Incident Place – the primary place at which the event(s) giving rise to the claim occurred. Circle the appropriate code and give the name of the health care facility if applicable.
• Physician’s Role – the physician’s relationship to the patient involved in the incident or occurrence. Circle the appropriate code.
• Nature and Substance of Claim – provide a summary of the major allegations, including a description of the precise error, omission or negligence alleged. The response to this item should not merely repeat vague or general allegations that may appear in the complaint. In addition to the summary, provide up to eight (8) basis codes from the attached table.
• Lawsuit Filed? – if a lawsuit was filed in relation to the claim, circle the code for the venue (county) in which the case was filed and provide the docket number and case name. If the case went to trial, check if the trial was before a judge only (no jury).
• Final Disposition – check as many disposition options as apply, and indicate the amount of the judgment or settlement, if applicable.
• Total Award/Judgment/Settlement – the amount of the indemnity payment is to be calculated as follows (indicate interest on a separate line):
  1. if a jury verdict/judgment – the amount approved by the trial court (e.g., after granting a motion to reduce the jury award).
  2. if a settlement – the total amount of indemnity to be paid to the claimant/plaintiff with regard to the event that gave rise to the claim, whether or not the amount will be paid, in part, by the physician or by an entity or person other than the reporting insurer.
  
  
• Contribution by Reporting Insurer – the portion of the indemnity payment that has been or is to be paid by the reporting insurer on behalf of the physician who is the subject of the report (indicate interest on a separate line.)
• Structured Settlement/Payment – if the indemnity payment is a structured settlement or payment, present value is to be calculated as of the date of the final judgment or settlement, as defined on page one. Monetary amounts set forth in this item should include interest.
• Claimant/Plaintiff – the name, address and date of birth of the person who allegedly was injured. If the claimant/plaintiff is not the injured party, identify both this person and the injured party(ies), and list their names and addresses. Use a separate sheet, if necessary.
• Additional Defendants – list all other Massachusetts licensed physicians (see definition of Physician Information) who were involved in the incident or occurrence detailed in this report. Please include their addresses and license number, if available. Use a separate sheet, if necessary.

Questions should be addressed to the Board's Data Repository Counsel at (781) 876-8200.