CLAIMS MANAGEMENT AND HANDLING

CLAIMS MANAGEMENT AND HANDLING Russell Jones Claims Manager, VMIA Introduction  Team Programs: – Public Healthcare – General Government – Community Service Organisations – Rail – Others  Introduction (cont.)   Coverage Classes – Medical Indemnity – Public and Products – Material Damage – Employment Practices – Directors and Officers – Contract Works – Travel – Volunteers – Motor – Etc. Other Teams – Asbestos Run-off – Housing Guarantee Fund Statistics  Reserves: – Public Healthcare: – – General Government: CSO: Approximately $643 million Pay P/A $35 – $40 million Approximately $69 million Pay P/A $12 - $15 million Approximately $5.0 million Pay P/A $1.5 million   Reserve for full value ASAP Incidents: – Public Healthcare: – General Government: – Other: 80,000 p.a. 1,500 p.a. 1,000 p.a. Statistics (cont.)   Claim Numbers: – Public Healthcare: – General Government: – Other: Deductibles: – Public Healthcare: – General Government: – Other: 1,000 - 1,200 p.a. 450 p.a. 350 p.a. Nil Various Nil  Claim Trends: – Post amendments to the Wrongs Act Medical Negligence Cases filed in the County Court of Victoria (as at 20/10/2003) Relationships         Other parties Reinsurers Health Insurance Commission Plaintiff lawyers Courts Clients MDO’s Service Providers What are our thought processes? This is not a “one glove fits all” approach and is very dependent upon the circumstances of a claim and whether it will/will not be fully litigated. What are our thought processes? (cont.) Liability – assume serious incident. Where it is more likley than not that a claim will arise:  Notification / advice - assimilate factual situation  Privilege / FOI  Policy – Indemnity  Liability  Recovery  Third Parties  Contribution  Legislation: – Wrongs Act – Statute of Limitiations What are our thought processes?        (cont.) What assistance does the client require? Legal assistance Quantum Strategy Conflicts Trial preparation Debriefing Simpson - v - Diamond: Total $14,202,042 What are our thought processes?  (cont.) Property – assume early notification: – Dependant on nature of claim – Policy indemnity:  Loss recovery experts  Loss Adjusters  Builders (We do not have to go out to tender) – – – OH&S issues Site protection Union issues What are our thought processes?  (cont.) Property (cont.): – Quantum assessment – Mitigation – Liability – Recovery – Salvage – Strategy Mediation - v - Trial         We get involved Canvas issues Contain damage (in its various forms) Plaintiff expectations Settlement rate at mediation No win / No fee Contrast Vic with NSW Control quantum (try not to raise the bar) Cases that went to trial 1. 2. 3. 4. Simeon Akbulat Azin Mitchell Contrast with a Rural Doctor claim Why did these cases get to trial? What we do?           85% of work is litigation – model litigant principles Advice Client visits Claim reviews Liaise with internal Risk Management/Client Risk Management Unique ways of handling matters Lessons from losses Working groups 24 hour contact Contemporaneous issues Claims Process Flowchart 24 Hour contact all classes of claim and/or advice if claim the addressed under Internal assessment advice to client Liaise with client on suppliers and assessment of claim, appoint suppliers as required and advise clients If 3rd Parties involved, negotiating resolution and advising client Property claim all programs Advice to client on mitigation, action being instituted, policy cover, indemnity, deductible External Assessors advise client of appointment Resolve advise to client Liaise with client and Loss Adjuster on present position and negotiating on significant issues Progress payments as appropriate with explanation to client Appoint Solicitors if required, i.e. recovery. Advise client of appointment Involvement of Solicitor at this stage if required If recovery action necessary garnering client input to process and facilitating dealing with Solicitors Mediation Trial Liaison with client on present position/investigation Claim managed internally Appointment of Investigator/ Assessors Assessment of claim having regard to evidence and legislation Resolve claim and advise client Liability claim nonmedical indemnity Advice to client Contact with claim/claimant’s Solicitor/claimant’s Representative Liaise with client as appropriate Claim not resolved litigated refer to lawyers Advise client of appointment Claim allocated to Lawyers Defence prepared after liaising with client Interlocutory steps completed after liaising with client Admission of liability? Client consent obtained Claim resolved Client advised Client advised of risk management issues Lawyers investigate and advise VMIA Mediation ordered Mediation Client advised Further consideration given to admission of liability Risk Management lessons advised to client Client advised of verdict VMIA discussions reviews with client as appropriate Issues identified clarified with client Claim not resolved set down for trial Client advised of witnesses required to give evidence Witnesses prepared with Counsel Trial Not litigated Claim managed internally Client input evidence Expert advice obtained Conciliate or resolve claim Client advised of outcome Risk management issued identified to client Expert evidence reviewed Strategy on claim reviewed Liaising with client and witnesses If claim cannot be resolved and proceedings instituted or pursued, refer to lawyers Further orders attended to Liability claim Medical Indemnity HSC Advice to client Contact with plaintiff’s lawyer Client contact to VMIA. Nature of query broken into broad categories as follows. Litigated Lawyer investigate through director of medical services and advise VMIA VMIA and Solicitor consult with hospitals) if conflict Admission of liability? Client consent obtained Defence completed and filed after liaising with client Interlocutory steps completed after liaising with client Claim resolved Client advised Client advised of risk management issues Claim allocated to lawyers Advise client of appointment Mediation ordered Meditation Client advised Issues identified and clarified with client Claim not resolved set down for trial Contribution not agreed refer to arbitration (if not to trial) Client advised of witnesses required to give evidence Further consideration given to admission of liability VMIA discussions Statements, strategy, policy, indemnity, litigation, legal, open disclosure, conflict, etc. If conflict appoint further law firm if conflict cannot be resolved Witnesses prepared with Counsel Advise to clients stakeholders Open claim or follow up if appropriate Risk Management lessons advised to client Client advised of verdict Trial …….. Evidence reviewed If other MDO involved, liaise as necessary on contribution, etc. Common law claim in conjunction with coronial Rural Doctor If conflict advice to clients Strategy on claim reviewed Refer to litigated claim as above Further orders attended to Liaising with client and witnesses Coronial Appoint lawyers and advice client VMIA cover advice Evidence gathered, statements obtained, copy coroners brief concessions (if any by hospital) Coronial enquiry Coroners findings Advice to client Hospital, CHS, etc VMIA liaising with client Not covered VMIA advice Resolved advise client EPL Refer to lawyers and advise client Lawyers obtain statements evidence Conciliation in AIRC Not resolved advice to client Proceed to hearing Judgment advice to client Board determine on papers Advise client Rural Doctor MPBV VMIA cover advice Refer to lawyers and advise client Board determine to go to hearing Hospital, CHS, etc Not covered by VMIA Advise client Review evidence MPBV hearing NRBV (Hospital, CHS, etc.) Not covered MDOs, Courts, AMA, etc. Other Stakeholders Claim reviews with clients Lessons from losses Seminars Practitioner meetings Conflict meetings Working groups Can we be at odds with you / Plaintiff?  Yes – we will not always agree  We are almost always at odds with a Plaintiff and their lawyers What would I like from you?     Contact us ASAP (pick up the phone) Do not admit liability Promptly prepare Co-operation: – VMIA – Lawyers – Loss Adjusters Legal Panel        Deacons Lander & Rogers Middletons Minter Ellison Monahan + Rowell Phillips Fox TressCox Lawyers Claims Section Contact Directory Name Russell Jones Doug Gallagher Michael Walsh Steve Ribarich Colin MacRae Annette Nola Dean Sutton Daniela Moretti Michelle Stuart Title Claims Manager Claims Executive Claims Executive Claims Officer Claims Executive Claims Officer Claims Assistant Administrative Claims Assistant Claims and Administrative Officer Email Address r.jones@vmia.vic.gov.au d.gallagher@vmia.vic.gov.au m.walsh@vmia.vic.gov.au s.ribarich@vmia.vic.gov.au c.macrae@vmia.vic.gov.au a.nola@vmia.vic.gov.au d.sutton@vmia.vic.gov.au d.moretti@vmia.vic.gov.au m.stuart@vmia.vic.gov.au Direct Number 9911 6929 9911 6925 9911 6928 9911 6934 9911 6920 9911 6975 9911 6990 9911 6960 9911 6965 Mobile Number 0408 453 229 0408 056 564 0408 591 823 --0407 535 630 --------- Questions