31.08.10.04

.04 Required Information.

The following information shall be reported on a closed claim survey form:

A. Name of insurer;

B. Name of insurer group;

C. Claim file identification (ID);

D. Name of person completing the form;

E. Telephone number, including area code, of person completing the form;

F. Date form completed;

G. Date of injury;

H. Date injury reported to insurer;

I. Date claim closed;

J. Whether the claim was previously reported;

K. Age of injured person at time of injury;

L. Gender of injured person at time of injury;

M. Type of injury, such as wrongful death, permanent disability, or other bodily injury;

N. Description of injury;

O. Name of health facility where injury occurred;

P. Type of medical professional liability policy, such as occurrence, claims made—basic, or claims made—tail;

Q. Type of patient, such as inpatient, emergency room outpatient, or other outpatient;

R. Physician Insurance Services Office Incorporated (ISO) classification or equivalent classification;

S. Type of health care provider, such as physician-no surgery, surgeon, psychiatrist and related specialties, nurse, nurse midwife, optometrist, pharmacist, chiropractor, podiatrist, psychologist, dentist, hospital, other health care facility, or nurse anesthetist;

T. Physician and surgeon classification, including name of specialty;

U. Health care provider name;

V. Health care provider license number;

W. Policy limits for each claim or medical incident;

X. Policy limits for annual aggregate;

Y. If known, the facility, office, or county where the injury occurred;

Z. Whether the claim is a zero payment claim file;

AA. Full name and location of the court where the suit was filed and the case was tried;

BB. Case or docket number;

CC. Whether settlement was reached or award was made at one of the following stages:

(1) Arbitration;

(2) Mediation before suit was filed;

(3) After suit was filed, but before trial;

(4) During trial, but before court verdict;

(5) Court verdict;

(6) After verdict; or

(7) After appeal was filed;

DD. If settlement was reached or award was made by court verdict, whether the result was:

(1) Directed verdict for plaintiff;

(2) Directed verdict for defendant;

(3) Judgment notwithstanding the verdict for plaintiff;

(4) Judgment notwithstanding the verdict for defendant;

(5) Judgment for plaintiff;

(6) Judgment for defendant;

(7) Judgment for plaintiff, after appeal;

(8) Judgment for defendant, after appeal; or

(9) Any other;

EE. If there was no final judgment or settlement, the date of the final disposition;

FF. If there was no final judgment or settlement, the reason for the final disposition;

GG. If case did go to trial, whether the case was tried by a jury or tried by a judge;

HH. Total amount paid to the claimant;

II. Amount paid by the insurer;

JJ. Amount paid by the insured due to retention or deductible;

KK. If known, the amount paid by an excess carrier;

LL. If known, the amount paid by the insured due to settlement or award in excess of policy limits, not including deductible or retention amounts;

MM. If known, the amount paid by the insurer due to settlement or award in excess of policy limits, not including deductible or retention amounts;

NN. If known, the amount paid by other defendants or contributors;

OO. A summary of the occurrence from which the claim or action arose;

PP. A description of the misdiagnosis or alleged misdiagnosis made, if any, of the patient's actual condition;

QQ. A description of the procedure giving rise to the claim;

RR. A description of the principal injury giving rise to the claim;

SS. The amount of past medical expenses claimed by the plaintiff;

TT. The amount of future medical expenses claimed by the plaintiff;

UU. The amount of past lost wages claimed by the plaintiff;

VV. The amount of future lost wages claimed by the plaintiff;

WW. The amount of noneconomic damages claimed by the plaintiff;

XX. The amount of other damages claimed by the plaintiff;

YY. Whether a structured settlement or periodic payment was used, and if so:

(1) The amount of immediate payment;

(2) The present value of the projected total future payout, that is, the price of the annuity, if purchased;

(3) The projected total future payout; and

(4) The cost of the structure;

ZZ. If a neutral expert was used, the findings of a neutral expert witness regarding future medical expenses;

AAA. If a neutral expert was used, the findings of a neutral expert witness regarding future loss of earning;

BBB. If case was tried to verdict:

(1) The amount awarded for past medical expenses;

(2) The amount awarded for future medical expenses;

(3) The amount awarded for past lost wages;

(4) The amount awarded for future lost wages;

(5) The amount awarded for noneconomic damages; and

(6) The amount awarded for other damages;

CCC. The total allocated loss adjustment expense;

DDD. Of the total allocated loss adjustment expense, the amount representing fees paid to defense counsel;

EEE. Of the total allocated loss adjustment expense, the amount of expenses not included in the defense counsel fees;

FFF. Whether there was a claim made for extra contractual damages;

GGG. The amount claimed for extra contractual damages;

HHH. Whether a suit was filed or claim was made for extra contractual damages; and

III. Where the suit for the extra contractual damages claim was filed, including:

(1) The full name of the court where the suit was filed and the case was tried;

(2) The case number or docket number;

(3) Whether the claim settled or was tried;

(4) If tried, whether the trial was before a judge or jury;

(5) The amount paid for the extra contractual damages claim; and

(6) Whether the claim was previously reported to the Commissioner.